Presented  by 
Harriet  L»  Connor,  D«  0« 


^ 

3     COLLEGE 


OF    OSTEOPATHIC     PHYSICIANS 

Q 

^      AND  SUR(;KONS  •    LOS  ANGELES,  CALIFORNIA 


GYNECOLOGICAL    DIAGNOSIS 


GYNECOLOGICAL 
"     DIAGNOSIS 


BY 

WALTER  L.  ^URRAGE,  A.M.,  M.D.  (HARV.) 

Fellow  of  the  American  Gynecological  Society ;  Member  of  the  Obstetrical  Society  of 
Boston ;  Consulting  Gynecologist  to  St.  Elizabeth's  Hospital ;  Formerly  \7isiting 
Gynecologist  to  St.  Elizabeth's  and  the  Carney  Hospitals  ;  Electro- 
Therapeutist  and  Surgeon  to  Out-Patients,  Free  Hospital 
for  Women;    Clinical  Instructor  in  Gynecology, 
Harvard  University,  and  Instructor  in 
Operative   Gynecology  in  the 
Boston  Polyclinic 


NEW   YORK   AND    LONDON 
D.  APPLETON   AND   COMPANY 

1910 


COPYRIGHT,  1910,  BT 
D.  APPLETON  AND  COMPANY 


PHINTED    IN    NKW   YOHK,    XT.    S.    A. 


"  Find  out  the  cause  of  this  effect — 
Or  rather  say,  the  cause  of  this  defect, 
For  this  effect  defective  comes  by  cause." 

— Hamlet,  Act  ii,  Scene 


PREFACE 

SOME  years  ago  a  prominent  surgeon  who  had  been  attending  one 
of  my  clinics,  remarked  when  the  clinic  was  over:  "I  think  I  under- 
stand the  treatment  and  I  know  how  to  do  most  of  the  gynecological 
operations,  but  where  I  find  great  difficulty  is  in  the  diagnosis." 

At  the  present  time  the  medical  profession  is  devoting  an  ever- 
increasing  amount  of  attention  to  diagnosis,  and  it  seems  fitting  to 
describe  at  length  this  somewhat  blind  subject,  gynecology,  for  the 
benefit  of  those  who  have  not  had  an  opportunity  to  study  it  in  the 
special  hospitals  and  clinics. 

A  practical  text-book,  embodying  simplicity  of  technique  and 
concise  statement  of  essentials,  has  been  the  aim.  The  methods  of 
procedure  of  the  pathological  and  bacteriological  laboratories  have 
been  omitted  because  of  the  assumption  that  'the  physician  in  making 
a  diagnosis  has  always  at  his  command  the  services  of  a  trained 
pathologist  and  bacteriologist,  or  can  consult  text-books  devoted 
exclusively  to  these  subjects.  The  attempt  has  been  made  to  keep  in 
the  background  the  rare  diseases  which  are  of  so  much  interest  to  the 
specialist  and  to  give  prominence  to  the  common  affections  usually 
met  by  the  general  practitioner.  While  the  book  is  written  entirely 
from  the  clinical  point  of  view,  the  salient  points  of  the  anatomy 
and  the  latest  views  of  the  pathology  have  been  summarized  at  the 
beginning  of  each  chapter,  and  the  literature  has  been  scanned  for  new 
ideas  of  value  to  the  practitioner. 

The  differential  diagnosis  is  entered  into  extensively  and  is  sum- 
marized in  many  places  in  the  form  of  tables  of  parallel  columns. 

Particular  attention  has  been  paid  to  the  diagnosis  of  the  diseases 
of  the  bladder  and  of  the  rectum  because  of  my  belief  that  these 
organs  are  too  often  neglected.  A  chapter  on  diseases  of  the  breast 
has  been  included  because  the  breast  is  a  part  of  the  reproductive 
system  in  women  and  has  intimate  relationship  with  the  uterine 
organs.  The  importance  of  the  recognition  of  uterine  disease  in  early 
life,  which,  when  undiscovered,  frequently  causes  disastrous  results 
later,  has  led  to  the  writing  of  the  chapter  on  the  gynecological  affec- 
tions of  infancy  and  childhood.  In  the  preparation  of  this  chapter 
I  have  been  fortunate  in  having  the  assistance  of  my  friend,  Dr. 


22918 


viii  PREFACE 

John  Lovott  Morse,  who  kindly  revised  the  manuscript.  The  chapter 
on  the  menopause  is  an  attempt  to  shed  light  on  this  important  but 
little  understood  period  of  woman's  life. 

An  original  feature  of  the  book  is  an  alphabetical  index  of  illus- 
trations— of  which  there  are  two  hundred  and  fifteen — in  the  front. 
Thus  the  reader  can  find  any  desired  figure  without  laboriously 
going  through  the  entire  list.  The  attempt  has  been  made  to  place  each 
figure  next  to  the  text  it  illustrates  and  all  references  to  figures,  as  well 
as  to  subjects  cited  in  other  parts  of  the  book,  are  accompanied  by 
page  numbers.  Every  chapter  is  headed  by  a  resume  of  its  contents 
with  page  references,  and  all  the  illustrations,  as  well  as  the  titles  of 
the  subject-matter,  are  also  included  in  a  very  full  index  at  the  end. 

The  views  here  expressed  and  the  methods  described  are  those 
that  have  found  favor  in  my  practice,  and  they  are  put  forward  not 
with  the  feeling  that  they  arc  new,  original,  or  all-inclusive,  but  that 
having  proved  useful  to  me  they  may  help  others  also  to  unravel  the 
knotty  problems  of  gynccology. 

My  thanks  are  due  to  Dr.  Howard  A.  Kelly,  Dr.  E.  C.  Dudley,  and 
the  other  authors  who  have  kindly  loaned  illustrations  from  their 
works;  to  Dr.  Henry  T.  Hutchins  for  revising  the  chapter  on  malig- 
nant diseases  of  the  uterus  and  the  section  on  the  collection  of  the 
discharges  and  tissues  for  microscopic  examination;  to  Dr.  Howard 
W.  Beal  for  assistance  with  the  section  on  indirect  cystoscopy;  to 
Miss  Florence  L.  Spaulding  and  Miss  Ruth  O.  Huestis  for  original 
drawings;  and  especially  to  Messrs.  D.  Applcton  and  Company, 
who  have  shown  never-failing  courtesy  and  who  have  assisted  in  every 
possible  way  in  the  making  of  the  book. 

WALTER  L.   BUBRAGE. 
BOSTON 


CONTENTS 


PART  I 

GENERAL   CONSIDERATIONS 

PAGE 

CHAPTER  I.  INTRODUCTION   .     . 3 

CHAPTER  II.         THE  CLINICAL  HISTORY 5 

CHAPTER  III.       THE  INTERPRETATION  OF  THE  CLINICAL  HISTORY      .     .        9 

CHAPTER  IV.        THE  PHYSICAL  EXAMINATION 23 

I.  The  preparation  of  the  patient. — II.  The  prepar- 
ation of  the  examining  table. — III.  The  exam- 
ination: 1.  Preparation  of  the  physician  and 
placing  the  patient  on  the  table.  2.  Inspection 
of  the  external  genitals.  3.  Palpation. 

CHAPTER  V.          THE  PHYSICAL  EXAMINATION  (Continued) 43 

III.  The  examination  (continued):  3.  Palpation 
(continued).  4.  Odor  as  a  diagnostic  sign.  5.  The 
collection  of  the  discharges  and  tissues  for  micro- 
scopic examination. 

CHAPTER  VI.        THE  PHYSICAL  EXAMINATION  (Continued) 64 

III.  The  examination  (continued):  6.  Inspection  of 
the  abdomen.  7.  Palpation  of  the  abdomen. 
8.  Percussion  of  the  abdomen. 

CHAPTER  VII.      THE  PHYSICAL  EXAMINATION  (Concluded) 77 

III.  The  examination  (continued):  9.  Instruments 
and  their  use  in  diagnosis. 

CHAPTER  VIII.     THE  INVESTIGATION  OF  THE  URETHRA,  BLADDER,  AND 

URETERS 99 

CHAPTER  IX.        THE  INVESTIGATION  OF  THE  RECTUM 121 

CHAPTER  X.         THE  SIGNIFICANCE  OF  THE  CHIEF  SYMPTOMS  OF  PELVIC 

DISEASE 127 

ix 


CONTENTS 


CHAPTER  XI. 
CHAPTKK  XII. 
CHAPTEK  XIII. 

CHAPTER  XIV. 
CHAPTER  XV. 
CHAPTER  XVI. 

CHAPTER  XVII. 
CHAPTER  XVIII. 
CHAPTER  XIX. 
CHAPTER  XX. 
CHAPTER  XXI. 
CHAPTER  XXII. 

CHAPTER  XXIII. 
CHAPTER  XXIV. 
CHAPTER  XXV. 
CHAPTER  XXVI. 
CHAPTER  XXVII. 
CHAPTKK  XXVIII. 

CHAPTER  XXIX. 


PART  II 

SPECIAL    DIAGNOSIS 

PAGK 

THE  DIAGNOSIS  OF  ENDOMETRITIS,  INCLUDING  GONOR- 
RHEA AND  EROSIONS  OF  THE  CERVIX  UTERI    .     .     .  1G.5 

THE    DIAGNOSIS    OF  PELVIC  INFLAMMATION   (PELVIC 

PERITONITIS   AND  PELVIC  CELLULITIS)      .     .     .  187 

THE  DIAGNOSIS  OF  CONGENITAL  ANOMALIES  OF  THE 
UTERUS,  LACERATION  OF  THE  CERVIX  UTERI,  AND 

DISEASES  OF  THE  UTERINE  LIGAMENTS     ....  197 

THE  DIAGNOSIS  OF  MALPOSITIONS  OF  THE  UTERUS    .  215 

THE  DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS  244 

THE    DIAGNOSIS    OF    MALIGNANT    DISEASES    OF    THE 

UTERUS 266 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES      .     .  284 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  FALLOPIAN  TUBES  324 

THE  DIAGNOSIS  OF  EXTRA-UTERINE  PREGNANCY  .     .  340 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  VAGINA  .     .     .  354 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  VULVA    .     .     .  388 

THE  DIAGNOSIS  OF  UTERINE   PREGNANCY,  ABORTION, 

AND  HYDATIDIFORM  MOLE 417 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  URETHRA    .     .  444 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  BLADDER     .     .  457 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  URETERS     .     .  486 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  RECTUM       .     .  494 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  BREAST        .     .  531 

THE  DIAGNOSIS  OF  THE  GYNECOLOGICAL  AFFECTIONS 

OF  INFANCY  AND  CHILDHOOD  555 


THE  MENOPAUSE  AND  OLD  AGE 
INDEX    . 


LIST  OF  ILLUSTRATIONS 


ABDOMEN,  cavity  of,  shape  of 86  221 

division  of,  into  quadrants  and  indication  of  bony  landmarks        .18  65 

organs  of,  origin  of  tumors  in 129  304 

Anal  canal 191  495 

cast  of         192  496 

Anal  region,  diagram  of 195  515 

Applicator,  uterine       37  93 

Ascites,  abdomen  of,  seen  in  profile 131  307 

cross  section  of,  dorsal  position 132  310 

lateral  position       133  311 

BARTHOLIN'S  gland,  cyst  of  left        174  409 

Bartholin's  glands,  abscess  of 176  411 

abscess  of  ducts  of 175  410 

Bladder,  ballooned  by  air,  patient  in  knee-chest  position 54  112 

base  of,  showing  diverticula        185  458 

normal,  laid  open  from  in  front 51  106 

overdistended        84a  217 

papilloma  of         190  482 

stone  in       186  463 

tuberculosis  of  ureteral  orifice  in 187  469 

varix  of       188  474 

Bladder  phantom,  for  practising  cystoscopy 58  118 

Blood  vessels,  uterine  and  ovarian 8  47 

Body,  vertical  median  section  of 6  44 

of  childbearing  woman          84  216 

Breast,  diffuse  bilateral  hypertrophy  of 201  541 

dissection  of  lower  half  of,  showing  milk  ducts 198  534 

division  of,  into  quadrants 200  538 

lymphatics  of        199  535 

right,  vertical  section  of 197  533 

scirrhous  cancer  of 202  547 

CALIBRATOR,  meatus,  Kelly 44  101 

Carunculse  myrtiformes          165  397 

Catheter,  bladder,  long  silver 43  101 

ureteral,  Kelly 48  103 

Cervix,  adeno-carcinoma  of  canal  of,  early  stage Ill  268 

cancer  of,  early  stage 110  267 

erosion  of,  with  lacerations 69  185 

fibroid  of , 108  254 

hypertrophic  elongation  of 88a  225 

xi 


xii  LIST  OF   ILLUSTRATIONS 

FIG.  PAGE 

Cervix,  laceration  of,  bilateral,  with  erosions 79  205 

crescent  ic 81  207 

stellate 80  206 

unilateral  (diagram)        83  209 

with  eversion  of  lips  (diagram) 82  209 

prolapse  of        88  224 

squamous-celled  cancer  of,  early  stage 110  267 

supravaginal,  elongation  of 88  224 

Controller,  current,  for  use  with  electric  cystoscope 57  117 

Curette,  uterine        31  90 

Cylinder,  vertical,  filled  with  fluid,  representing  abdominal  cavity        .       7  45 

Cystocele          148  367 

diagram  of        148a  368 

Cystoscope,  bladder,  Kelly 49  104 

ureter,  Nitzo 56  116 

Cystoscopy,  mollified  knee-chest  position  used  in 53  111 

removing  urine  from  bladder  in,  by  suction  apparatus 55  113 

DECIDUA,  uterine,  in  extra-uterine  pregnancy 143  345 

Depressor,  vaginal,  Hunter         29  89 

Dilator,   urethral,   double-ended,  Kelly        45  102 

uterine,  Wathen        34  92 

uterine,  Hanks 33  91 

ENDOMETRIUM,  normal 65  167 

Enteroptosis,  body  pose  in 19  67 

Evacuator,  bladder,  Kelly 46  102 

wash-bottle,  Kelly 55  113 

Extra-uterine  pregnancy,  ampullar,  early 140  341 

mole  and  fetus  removed 141  342 

ampullar,  late 145  350 

isthmial,  section  of  uterus  of 146  352 

FALLOPIAN  tubes,  development  of,  in  fetus 71  198 

Fissure  in  ano 194  504 

Fistula  in  ano,  blind  internal 196a  517 

complete 196  517 

Fistula*,  genital,  scheme  of,  after  Dudley           189  476 

after  (iilliam 155  385 

Forceps,  bladder,  alligator 50  105 

curette,  Emmet 30  89 

rectal,  alligator 62  125 

uterine  dressing,  Bo/.eman 23  83 

vulsellum 25  84 

CiArzK  records  of  abdominal  tumors 20  75 

CJenital  organs,  development  of,  five  diagrams  illustrating      .     .     158-162  395 

external,  at  beginning  of  iliird  month       ....           l.~>7  ;W2 

Gland,  Bartholin's,  cyst  of  left                                                                     .    17  |  4()<» 


LIST  OF  ILLUSTRATIONS  xiii 

FIG.   PAGE 

Glands,  Bartholin's,  abscess  of 176  411 

abscess  of  ducts  of 175  410 

HAND,  examining,  showing  protective  sleeve 2  31 

Hegar's  method  of  palpating  pedicle  of  ovarian  tumor 126  301 

sign,  bimanual  palpation  for  179  425 

Hematocele,  pelvic  142  343 

Hematocolpos,  diagram  of 171  393 

Hematometra,  diagram  of 172  398 

Hematosalpinx 139  335 

diagram  of  173  399 

Hemorrhoids,  types  of 193  499 

Hydatidiform  mole 182  442 

Hydrosalpinx 138  334 

Hymen,  different  forms  of 163-170  397 

INTERSTITIAL  pregnancy        144  346 

Irrigator,  uterine,  Bozeman-Fritsch 35  92 

Isthmial  tubal  pregnancy,  section  of  uterus  of 146  352 

LIGAMENTS,  utero-sacral,  course  of,  in  intraligamentous  tumor        .     .  135  317 

in  retroperitoneal  tumor 134  316 

MATURITY,  precocious,  case  of 207  565 

"Milk  line," 200  538 

Os,  external,  parous 66a  169 

virginal 66  168 

Ovaries,  infantile 117  286 

Ovary,  cyst  and  tumor  regions  of 120  290 

cyst  of,  adherent,  arrangement  of  peritoneum  in 124  292 

intraligamentous,  arrangement  of  peritoneum  in        123  292 

pedicle,  arrangement  of  peritoneum  in 122  292 

very  large,  showing  emaciation  and  "  facies  ovarina  "     .     .     .        125  294 

normal,  pedicle,  arrangement  of  peritoneum  in 121  292 

of  mature  woman 118  287 

senile 119  289 

tumor  of,  cross  section  of  body  of 127  302 

tumors  of,  Hegar's  method  of  determining  relation  of,  to  uterus      .   126  301 

pedicle,  formation  of  (4  diagrams) 121-124  292 

Ovary  and  tube  seen  from  behind 116  285 

PAROVARIUM,  large  cyst  of,  seen  in  profile 128  303 

Pelvimeter       .     .     .     . t     ...     42  98 

Pelvis,  contents  of.  from  above 9  48 

female,  normal 9a  50 

showing  accessibility  of  contents  to  palpation 10  52 

with  hand  in  position  as  for  vaginal  examination 4  37 

floor  of,  diagram  showing  structures  of 150  373 

of  new-born  child,  longitudinal  median  section  of 204  558 


xiv  LIST  OF   ILLUSTRATIONS 

FIG.  PAGE 

Perineum,  laceration  of,  complete  median 151  374 

partial  lateral 152  375 

Peritoneum,  reflections  of  folds  of,  in  pelvis        70  189 

Position,  dorsal         3  32 

knee-chest         13  56 

bladder,  vagina,  and  rectum  ballooned  by  air  in 54  112 

modified  for  cystoscopy 53  111 

side-view,  showing  vertical  thighs 14  57 

lithotomy          15  58 

raised  pelvis 16  59 

Sims         11  53 

diagram  of        12  54 

standing 17  60 

Precocious  maturity,  case  of 207  565 

Pregnancy,  extra-uterine.     See  Extra-uterine  pregnancy 

interstitial         144  346 

tubal,  early  ampullar,  abortion   in 140  341 

mole  and  fetus  removed  from  tube 141  342 

isthmial,  uterus  of 146  352 

late  ampullar,  four  months' 145  350 

section  of  uterus,  showing  decidual  modification  in 146  352 

Probe,  uterine 22  82 

Procidentia           87  223 

Proctoscope,  long 61  124 

short        60  123 

Pyosalpinx 137  333 

RECTOCELE 149  369 

diagram  of  149a  370 

Rectum,  ballooned  by  air,  patient  in  knee-chest  position 54  112 

lower  part  of ,  diagram  of 195  515 

SALFINGITIS,  tuberculous 136  331 

Searcher,  ureteral,  Kelly        47  102 

Sound,  uterine 21  78 

Separator,  urine,  Luys 59  119 

Speculum,  bivalve.     See  Speculum,  vaginal,  Brewer  and  Graves 

rectal,  Sims 63  126 

uterine,  Burrage        36  93 

vaginal,  Brewer 26  87 

Edebohls 32  91 

Graves 27  87 

Sims 28  88 

TAHLE,  examining 1  27 

Tenaculum,  uterine 24  83 

Touch,  bimanual,  diagrammatic  drawing 5  38 

Tubercles  of  bladder  wall                                                                                    .  187  4(10 


LIST  OF  ILLUSTRATIONS 


URETER,  orifice  of,  jet  of  urine  spurting  from 52  107 

Urethra,  caruncle  of • 184  454 

mucous  membrane  of,  prolapse  of 183  449 

Uterine  organs  of  an  infant  at  birth  seen  from  above 205  562 

Uterus,  anteflexion  of,  in  the  little  girl 90  230 

pathological 91  231 

bicornis        74  199 

bicomute,  one  external  os,  two  uterine  cavities 78  201 

bipartitus          72  199 

body  of,  adeno-carcinoma  of,  early  stage      .     .     .     . 112  269 

horizontal  section  of  upper  part  of      . 67  171 

sarcoma  of 113  279 

cavity  of,  Kelly's  methods  of  exploration  of,  exploring  with  finger      41  97 

incising  anterior  wall 39  95 

transverse  incision  anterior  to  cervix 38  94 

laid  open        40  96 

chorioepithelioma  of  posterior  wall  of 114  281 

development  of,  in  fetus 71  198 

didelphys 73  199 

double,  with  double  vagina 147  358 

fibroids  of,  interstitial  and  submucous 104  248 

intraligamentous         105  249 

large  tumor  filling  pelvis  and  simulating  pregnancy       ....  109  256 

multiple 102  246 

polyp  in  vagina,  large 107  252 

submucous,  large,  showing  distortion  of  uterine  cavity     ....  106  250 

simulating  inversion 101  245 

pedunculated,  simulating  inversion         99  241 

simulating  partial  inversion        95  241 

subserous,  side  view  of  abdomen  containing  large  tumor       .     .     .  103  247 

tumor  of  cervix 108  254 

fundus  of,  height  at  various  weeks  of  pregnancy 130  306 

inversion  of  acute  puerperal 93  239 

complete       98  241 

with  pedunculated  subserous  fibroid  of  abdominal  evolution      .  100  241 

partial 97  241 

caused  by  submucous  fibroid         296  241 

of  left  horn 94  241 

normal,  position  of ' 6  44 

pregnant,  enlargement  of,  in  late  pregnancy 181  428 

pregnant  at  sixth  week,  diagrammatic  side  view,  during  contraction    178  423 

during  relaxation         177  422 

section  of 178  424 

prolapse  of 87  223 

partial 89  227 

reconstruction   of.  showing  shape  of   uterine   cavity   and   cervical 

canal 64  166 

retroposition  with  anteflexion 91  231 

retroversion  of 92  235 

caused  bv  overdistended  bladder                            84a  217 


xvi  LLST   OF  ILLUSTRATIONS 

no.  PAGE 

t'terus,  sarcoma  of        113  279 

section  of,  in  isthmiul  tubal  pregnancy 146  352 

transverse  longitudinal        68  172 

sept  us 75  199 

unicornis 76  199 

with  accessory  comu 77  199 

VAGINA,  ballooned  by  air,  patient  in  knee-chest  position 54  112 

chorioepithelioma  of,  metastatic 115  282 

cyst  of  anterior  wall  of 154  381 

cyst  of  posterior  wall  of 153  380 

development  of,  in  the  fetus 71  198 

double,  with  double  uterus 147  358 

infantile,  examination  of ,  with  cystoscope 205  559 

longitudinal  section  of,  showing  S-shaped  curve 85  219 

prolapse  of  88  224 

Vulva,  at  beginning  of  third  month  of  fetal  life 157  392 

diagram  of  156  389 

infantile  .  203  556 


PART    I 
GENERAL    CONSIDERATIONS 


CHAPTER  I 
INTRODUCTION 

DIAGNOSIS,  the  foundation  of  gynecology,  is  elusive.  The  con- 
sultant frequently  hears  it  said  by  the  attending  physician,  "Doc- 
tor, I  know  how  to  do  this  operation,  but  what  puzzles  me  is  to 
know  when  it  is  indicated." 

The  educated  touch  is  the  keystone  of  the  diagnostic  arch; 
symptomatology,  sight,  instrumentation,  microscopic  findings,  are 
but  accessories.  To  train  the  touch  requires  time  and  application. 
As  in  learning  any  handicraft,  the  beginning  is  of  great  importance. 
Those  who  neglect  to  perfect  themselves  in  the  proper  technique 
at  the  start,  who  never  acquire  "  good  form  "  as  they  say  in  athletics,- 
never  progress  beyond  a  moderate  degree  of  excellence.  The 
practitioner  who  persists  in  making  the  bimanual  examination  with 
the  patient  in  bed  or  on  a  yielding  surface,  or  neglects  to  incommode 
her  to  the  extent  of  causing  to  be  loosened  all  clothing  about  the 
waist,  never  becomes,  a  good  diagnostician.  The  reasons  for  this 
will  appear  later. 

There  is  no  department  of  medicine  in  which  the  patient  is  less 
able  to  judge  from  her  own  observation  of  the  correctness  of  the 
diagnosis  than  in  gynecology.  Unlike  the  dermatologist,  for  ex- 
ample, the  gynecologist  does  not  have  trained  upon  his  work  the 
critical  eye  of  his  patient. 

She  is  unable,  also,  to  judge  of  the  nature  of  the  treatment  em- 
ployed. It  is  especially  easy  for  a  physician  who  has  made  an  error 
in  diagnosis  to  persist  in  a  chosen  line  of  treatment  without  dis- 
covering his  mistake,  for  the  relations  between  cause  and  effect  are 
often  most  shadowy;  also,  consultations  are  relatively  infrequent 
in  this  department  of  medicine.  Because  of  the  delicate  nature 
of  the  confidences  called  for,  and  the  sensitive  portion  of  the 
anatomy  involved,  the  patient  shrinks  from  subjecting  herself  to 
repeated  examinations  at  the  hands  of  different  physicians. 

3 


4  INTRODUCTION 

We  have  to  do  in  this  book  with  the  question  of  diagnosis  alone 
and  it  will  be  my  endeavor  to  point  out  how  best  to  make  it.  More 
stress  will  be  laid  on  the  interpretation  of  symptoms  and  signs  in 
the  light  of  experience  than  is  usual  in  text-books  on  gynecology 
because  it  is  thought  thereby  to  help  the  practitioner. 

That  pathological  conditions  may  exist  without  any  symptoms 
at  all  should  never  be  forgotten.  For  instance,  a  woman  may  have 
a  double  uterus,  detected  for  the  first  time  at  the  gynecological 
examination  which  follows  labor,  or  a  patient  may  have  a  small 
dermoid  tumor  of  the  ovary,  discovered  only  when  she  comes  to 
the  physician  to  learn  why  she  has  never  had  children. 

A  judicious  combination  of  the  deductive  and  inductive  methods 
seems  to  be  the  most  practical  way  of  presenting  the  subject;  a 
result  accomplished  by  describing  the  steps  of  the  examination  and 
the  processes  followed  in  arriving  at  a  diagnosis,  as  nearly  as  may  be, 
as  they  occur  in  actual  practice. 

Particular  attention  is  paid  to  the  minutiae  of  the  history-taking, 
the  management  of  the  patient,  and  the  smallest  details  of  the  ex- 
amination, because  of  my  belief  that  matters  which  seem  trivial  to 
many  arc  in  reality  the  solid  groundwork  of  a  correct  diagnosis. 

Mistakes  in  diagnosis  are  unavoidable  even  in  the  experience  of 
the  most  expert.  To  make  a  mistake  because  an  inadequate  ex- 
amination was  made  or  no  examination  at  all  is  an  unpardonable 
sin.  PJxperience  teaches  that  finality  in  diagnosis  is  not  always  a 
possibility  in  gynecology,  and  even  after  the  most  painstaking 
history,  analysis  of  the  symptoms,  and  physical  examination,  we 
may  fail  to  distinguish  between  two  or  three  possible  conditions. 
Our  object  is  to  reduce  the  uncertain  cases  to  a  minimum. 


CHAPTER  II 

THE  CLINICAL  HISTORY 

Method  of  getting  the  history,  p.  5.    Case-record  systems,  p.  6.     Form  for 
case  records,  p.  6. 

METHOD  OF  GETTING  THE  HISTORY 

MANY  busy  practitioners  slight  the  clinical  history,  the  taking 
of  which  should  precede  every  physical  examination.  This  is 
a  mistake  which  carries  its  own  retribution  in  the  form  of  a  slip- 
shod diagnosis.  A  clear  and  exhaustive  history  not  only  serves  as 
a  guide  in  making  the  physical  examination,  but  also  develops 
symptoms  which  otherwise  may  be  overlooked.  There  are  few 
cases  which  are  not  better  diagnosed  by  a  careful  preliminary 
questioning  of  the  patient.  The  physician  gains  his  patient's  con- 
fidence, so  necessary  for  a  successful  physical  examination.  If  she 
becomes  prolix  or  strays  from  the  important  point,  a  question  will 
often  bring  her  back.  It  is  well  to  note  especially,  perhaps  by 
underlining,  the  symptoms  that  seem  most  important  to  her,  so 
that  in  subsequent  interviews  these  may  be  under  special  observa- 
tion. It  is  generally  better  to  talk  with  the  patient  alone  when 
getting  the  history,  as  there  are  important  facts  which  will  be 
suppressed  if  a  third  person,  whether  a  nurse  or  a  relative,  be  present. 
Sometimes  it  happens,  however,  that  important  facts  are  to  be 
obtained  from  the  husband,  and,  in  the  case  of  a  young  girl,  from 
the  mother.  A  desirable  practice  is  to  review  the  history  after  the 
physical  examination  in  the  light  of  the  facts  brought  out  by  the 
examination  and  to  cross-question  the  patient  as  to  the  truth. 
Avoid,  as  far  as  possible,  asking  leading  questions  and  assenting 
too  readily  to  the  answers.  Be  sure  that  the  answers  represent  the 
truth. 

5 


THE    CLINICAL    HISTORY 


CASE-RECORD  SYSTEMS 

A  good  method  for  case  records  is  the  envelope,  card-catalogue 
system.  A  filing  cabinet  with  several  drawers  is  obtained.  Large, 
iingummed  envelopes,  and  also  a  set  of  cards  just  fitting  into  the 
envelopes  and  the  drawers  as  well,  are  procured.  For  use  at  the 
bedside  it  has  been  my  custom  to  carry  in  a  leather  pocket-case  a 
block  of  prescription  blanks,  six  by  four  inches,  which  fit  the  en- 
velopes of  my  filing  cabinet.  At  the  office  I  use  cards  of  the  same 
size.  Every  card  and  envelope  is  marked  on  the  left-hand  top 
corner  with  the  patient's  name  and  filed  alphabetically  in  the 
cabinet.  One  advantage  of  the  envelope  system  is  that  additional 
memoranda,  such  as  notes  on  treatment  and  other  data,  may  be 
filed  in  the  same  envelope,  and  it  is  not  necessary  to  copy  the  notes 
taken  at  the  bedside  before  filing  them. 

Many  gynecologists  have  printed  case  sheets,  either  in  a  book  or 
as  loose  pages  or  cards.  It  is  well  to  have  some  schedule  to  follow 
so  that  the  same  order  may  be  observed  in  all  cases  and  important 
facts  may  not  be  omitted.  To  the  beginner  a  printed  form  is  in- 
valuable, but  to  the  physician  of  experience  it  is  hardly  worth  while 
to  take  up  desirable  room  on  the  cards  with  printing  which  may  be 
of  no  use  in  many  of  the  cases.  The  object  is  to  get  a  schedule  in 
mind,  rather  than  to  have  it  printed  before  you. 


FORM    FOR    CASE    RECORDS 

Date  : 

Name  in  full  : 

(In  the  case  of  a  married  woman  both  own  first  name  and  hus- 
band's first  name  for  purposes  of  future  identification.) 
Address  :  Nationality  : 

Occupation  :  Age  : 

Social  Condition  :  Single.  Married,     (how  many  years) 

Widow  :   (how  many  years) 
Children  :     (how  many  and  ages) 

Miscarriages  or  abortions  :    (number,  and  at  what  weeks  or  months 
of  pregnancy.) 


Diagnosis: 

Family.  History. — General  predisposition  to  cancer,  lung  trouble, 
heart  disease,  kidney  disease,  or  rheumatism.  If  the  parents  are 
dead,  what  were  the  causes  of  death.  Early  or  late  occurrence  of 
the  first  menstruation  and  of  the  menopause,  or  the  occurrence  of 
dysmenorrhea  or  uterine  disease  in  sisters  or  female  relatives. 

Previous  History. — Special  reference  to  gynecological  affections; 
as  attacks  of  vulvar  inflammation,  or  smarting  with  micturition, 
as  indicating  gonorrhea;  "inflammation  of  the  bowels,"  as  indicat- 
ing pelvic  inflammation;  lack  of  control  over  the  bowels  or  bladder, 
showing  injury  of  the  sphincter  ani  or  of  the  pelvic  floor;  the 
account  of  any  operation  which  may  have  been  performed  on  the 
genital  organs.  The  infectious  diseases  may  point  to  inflammatory 
affections  of  the  vulva  and  vagina  in  childhood. 

Menstruation. — Age  at  which  first  menstruation  occurred;  whether 
normally  established,  the  subsequent  rhythm,  duration,  quantity, 
and  quality  of  the  flow;  whether  accompanied  by  pelvic  pain,  if 
so,  the  situation,  character,  and  duration  of  the  pain,  also  whether 
before,  during,  or  after  the  flow;  whether  disturbances  of  other 
functions  at  the  time  of  menstruation,  as  nausea,  headache,  de- 
pression of  spirits;  any  recent  irregularities  in  the  rhythm,  quan- 
tity, or  character  of  the  flow;  intermenstrual  pain,  if  so,  exact  dates 
of  beginning  and  end  of  pain.  Is  menstruation  accompanied  by 
leucorrhea,  or  not. 

Vaginal  Discharge. — Character,  amount,  when  most  in  quantity, 
duration. 

Pain. — Other  than  menstrual,  situation,  duration,  character. 

Confinements,  Miscarriages,  and  Abortions. — Labors  normal,  rapid, 
tedious,  or  instrumental;  whether  injuries  received  or  symptoms 
suffered;  convalescence  normal  or  not;  stitches  taken,  fever 
following.  Miscarriages  or  abortions,  dates  of  occurrence  and  at 
what  weeks  of  pregnancy;  supposed  cause  or  causes;  attended  by 
much  flowing  or  fever;  convalescence,  good  or  bad. 

Bladder  Symptoms. — Frequency  of  micturition  by  day  and  by 
night;  smarting  on  urination;  control  of  urine  on  laughing  and 
coughing  and  on  standing  and  walking;  pain  in  region  of  bladder 
on  micturition;  color  and  quantity  of  urine  passed. 

Present  Illness. — Duration;  particulars  as  to  present  symptoms 
such  as  pain,  situation,  character;  leucorrhea,  when  first  noticed, 


8  THE  CLINICAL   HISTORY 

character,  as  thin,  glairy,  thick,  purulent,  bloody,  or  offensive; 
whether  constant,  or  before  and  after  menstruation. 

Date  of  the  Beginning  of  the  Last  Menstruation. 

Abdominal  Swelling. — When  first  noticed,  progressive  increase 
in  size,  stationary  or  smaller,  painful  or  not. 

Bowels. — Regular  movement  every  day  or  constipated;  full 
action  or  scanty;  liquid,  semi-solid,  or  solid  stools;  offensive  odor; 
gas  in  bowels;  blood,  mucus,  or  pus  with  the  stools;  painful  de- 
fecation. 

General  Health. — Appetite,  digestion,  sleep;  whether  an  increase 
or  decrease  in  body  weight ;  headache ;  backache. 

The  General  Appearance  of  the  patient  should  be  noted  as 
regards  height,  approximate  weight,  complexion,  color  of  lips, 
peculiarities  of  form,  if  any. 

Analysis  of  Urine. 

Treatment  Advised. 


CHAPTER  III 


The  address,  nationality,  and  occupation,  p.  9.  Age,  p.  9.  Social 
condition,  p.  10.  Dypareunia,  p.  11.  Children,  11.  Family  history,  p.  12. 
Previous  history  p.  12.  Constitutional  diseases,  p.  12.  Chief  complaint 
and  present  illness,  p.  13.  Menstruation,  p.  13:  Puberty,  p.  14;  The 
menopause,  p.  16;  The  atrophic  changes  in  the  genital  organs  and  the 
body  alterations  of  the  menopause,  p.  17.  Vaginal  discharge,  p.  18.  Pain, 
p.  18.  Backache,  p.  18;  Muscular  rheumatism,  p.  19;  Coccygodynia, 
p.  19;  Pains  in  the  groins,  p.  19.  Abdominal  swelling,  p.  20.  Bladder 
symptoms,  p.  20.  The  bowels,  p.  21.  Present  illness,  p.  22. 

THIS  is  a  chapter  of  probabilities;  not  instructions  how  to  make 
an  offhand  diagnosis,  but  a  sifting  of  the  evidence  as  it  is  presented, 
the  diagnosis  being  held  in  reserve  until  after  the  physical  examina- 
tion, and  until  after  any  supplementary  evidence  has  been  elicited 
in  the  way  of  answers  to  questions  which  may  be  suggested  by  the 
examination. 

A  knowledge  of  the  normal  conditions  is  essential,  if  the  value  of 
the  abnormal  symptoms  is  to  be  estimated  correctly. 

The  Address. — This  is  important  not  only  as  a  matter  of  business 
but  as  showing  the  possible  effect  on  the  patient's  health  of  a  healthy 
or  an  unhealthy  locality. 

Nationality. — The  colored  race  is  especially  prone  to  fibroids. 
Cancer  is  seldom  found  in  a  negress. 

Occupation. — Confinement  in  poorly  lighted  and  ventilated  work- 
shops, long  working  hours,  heavy  lifting,  insufficient  food  and  pro- 
longed standing  on  the  feet  aggravate,  if  they  do  not  cause,  pelvic 
disorders.  On  the  other  hand,  a  sedentary  life  with  no  real  exercise 
may  act  as  a  contributory  cause  of  pelvic  disease. 

Age. — The  age  of  the  patient  suggests  the  special  disturbances 
found  in  the  various  epochs  of  life.  In  infancy  malformations  and 
inflammations  of  the  lower  genital  tract  are  to  be  expected.  At 
this  time  the  infections  are  generally  limited  to  the  vulva  and 
vagina,  and  tumors,  displacements,  and  traumatisms  seldom  exist. 
Vulvo-vaginitis  is  not  uncommon  in  little  girls. 

9 


10  INTERPRET ATIOX   OK  THE  CLINICAL   HISTORY 

Failure  of  the  mouses  to  appear  previous  to  the  sixteenth  year 
should  excite  no  apprehension  ;  after  that  it  is  apt  to  indicate  under- 
do velopment  of  the  uterine  organs. 

During  the  period  of  sexual  maturity  nearly  all  of  the  lesions  of 
the  genital  organs  may  be  found.  The  effects  of  gonorrhea  are 
seen  most  often  between  the  ages  of  twenty  and  thirty.  Tumors 
of  the  breast  arc  most  frequently  malignant  between  the  ages  of 
forty  and  sixty.  Under  the  age  of  thirty-five  a  large  abdominal 
tumor  is  more  likely  to  be  ovarian;  after  that  age  it  is  more  apt  to 
be  a  uterine  fibroid. 

A  patient  suffering  from  uterine  hemorrhage  more  probably  has 
endometritis  or  a  polypus  if  under  twenty;  a  polypus  or  some 
condition  resulting  from  gestation,  from  twenty  to  thirty;  fungous 
endometritis,  polypus,  or  fibroids  from  thirty  to  forty;  fibroids  and 
malignant  disease  from  forty  to  fifty.  After  fifty,  malignant 
disease1  is  the  probability. 

Social  Condition. — Congenital  malformations  may  be  brought  to 
the  patient's  attention  for  the  first  time  after  marriage.  Certain 
inferences  may  be  drawn  from  the  single  or  the  married  state  of  a 
patient  as  regards  the  cause  of  menorrhagia  or  metrorrhagia,  as 
shown  by  the  tables  on  pages  137  and  139,  Chapter  X.,  also  as 
regards  leucorrhea,  as  found  on  pages  144-146.  Pregnancy  is 
always  to  be  considered  if  the  patient  is  not  a  virgin.  An  early 
question  as  to  the  patient's  social  state,  whether  single,  married, 
or  a  widow,  may  obviate  embarrassing  queries  as  to  sexual  re- 
lations and  may  throw  light  on  the  possible  causes  of  her  com- 
plaints. For  instance,  a  recently  married  woman,  always  a  sufferer 
with  dysmenorrhea,  finds  the  symptom  aggravated  and  unbearable 
since  her  marriage.  A  periodic  pelvic  congestion,  due  to  mal- 
position or  malformation  of  the  uterus,  has  been  accentuated  by 
the  congestion  which  attends  sexual  relations.  A  recently  married 
woman  complains  for  the  first  time  of  smarting  on  urination,  and 
leucorrhea.  Suspicion  of  infection  with  the  gonococcus  at  once 
arises  in  the  physician's  mind.  The  possibility  of  pregnancy  or 
venereal  infection  should  never  be  lost  sight  of,  notwithstanding  the 
patient's  statement  that  she  is  single  or  a  widow,  great  caution  and 
tact  being  exercised,  however,  in  making  inquiries.  The  final 
question  as  to  the  truth  or  falsity  of  the  suspicion  should  be  left 
until  after  the  physical  examination  in  any  event,  and  in  many 


CHILDREN  11 

cases  can  not  be  made  at  all  without  causing  serious  and  unjustifi- 
able trouble  in  the  family  of  the  patient. 

Dyspareunia. — Dyspareunia  dating  from  the  time  of  marriage 
indicates  smallness  of  the  introitus  vaginae  or  urethral  caruncle, 
if  the  pain  is  at  the  beginning  of  coitus.  If  the  pain  is  experienced 
after  the  penis  has  been  introduced  into  the  vagina  the  cause  is 
apt  to  be  pelvic  inflammation  or  a  tender  cervix  or  ovary. 

Children. — Sterility. — The  absence  of  children  may  be  important, 
for  if  a  patient  has  been  married  many  years  and  has  not  been 
pregnant,  the  inference  is  that  the  cause  of  the  sterility  rests  with 
her  and  not  with  her  husband,  the  latter  being  in  good  health,  and 
we  may  expect  to  find  some  underdevelopment  or  malformation 
of  the  sexual  organs.  If  there  is  any  doubt  as  to  the  husband's 
virility  a  specimen  of  his  semen  should  be  examined  for  sperma- 
tozoa before  subjecting  the  wife  to  gynecological  treatment. 
(See  Chapter  X.,  page  147.) 

Carcinoma  of  the  cervix,  common  in  parous  women,  is  rare  in 
nulliparae,  whereas  cancer  of  the  body  of  the  uterus  is  more  apt  to 
occur  in  women  who  have  not  borne  children.  Complete  or  rela- 
tive sterility  is  often  found  in  women  suffering  with  fibroids. 

Number  of  Children. — The  number  of  children  a  woman  has  had 
is  important  because  child-bearing  without  a  sufficient  interval  of 
recuperation  between  the  labors  frequently  results  in  some  sort 
of  pelvic  ailment.  Therefore,  note  the  ages  of  the  children.  The 
history  of  each  confinement  is  of  the  greatest  service  in  determin- 
ing the  origin  of  a  pelvic  inflammation,  a  misplacement  of  the 
uterus,  or  lacerations.  A  difficult  forceps  delivery  followed  by 
fever  and  a  tedious  convalescence  may  mean  all  three,  though  not 
necessarily. 

Miscarriages  and  Abortions. — A  history  of  each  miscarriage  or 
abortion  should  be  secured  with  reference  to  the  birth  of  children ; 
if  before,  the  interruption  of  labor  can  not  be  due  to  injuries  re- 
ceived at  labor;  if  subsequent  to  a  difficult  and  complicated  con- 
finement, an  abortion  may  well  be  caused  by  the  labor.  The 
probable  cause  of  an  abortion  in  the  patient's  estimation,  whether 
attended  by  hemorrhage  or  fever  and  how  long  the  patient  was 
confined  to  her  bed,  are  points  to  be  ascertained.  These  facts  often 
reveal  the  starting  point  of  an  attack  of  pelvic  inflammation,  or 
anemia  and  subsequent  debility  due  to  loss  of  blood.  If  repeated 


12  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

abortions  have  occurred  they  may  indicate  syphilis,  tuberculosis, 
or  a  deeply  lacerated  cervix. 

Family  History. — How  much  of  a  role  heredity  plays  in  the 
etiology  of  pelvic  disease  is  not  determined.  Cancer  and  tuber- 
culosis are  found  occasionally  in  members  of  the  same  family.  It 
sometimes  happens  that  several  sisters  will  all  have  a  similar  lesion 
of  uterine  underdevclopment.  I  have  seen  three  sisters,  each 
suffering  from  marked  pathological  anteflexion.  A  premature  or 
delayed  occurrence  of  the  menopause  is  frequently  a  family  charac- 
teristic. So  is  the  symptom  of  dysmenorrhea.  Family  history,  as 
a  rule,  does  not  have  an  important  influence  on  diagnosis. 

Previous  History,  on  the  other  hand,  is  of  great  importance.  We 
have  noted  how  an  abortion  may  be  the  starting  point  of  an  attack 
of  pelvic  inflammation  to  be  followed,  perhaps  years  later,  by  serious 
lesions  of  the  pelvic  organs.  So  a  history  of  "inflammation  of  the 
bowels,"  without  assignable  cause,  may  mean  pelvic  inflammation, 
the  nature  of  the  treatment  employed  at  the  time  of  the  attack 
throwing  some  light  on  the  probable  diagnosis. 

An  attack  of  soreness  of  the  vulva  associated  with  a  purulent 
discharge,  with  or  without  smarting  on  urination,  may  well  mean 
gonorrhea. 

Adhesions  of  the  labia  minora,  and  of  the  prepuce  to  the  clitoris, 
and  even  imperforate  hymen,  may  be  caused  by  inflammation  of 
the  vulva  in  childhood  due  to  diphtheria,  scarlet  fever,  measles,  or 
gonococcus  infection.  Nocturnal  enuresis  is  caused,  sometimes, 
by  adhesions  of  this  sort.  Therefore,  when  possible,  the  mother 
of  the  patient  should  be  questioned  whether  her  daughter  had 
vulval  soreness  and  discharge  when  a  child. 

A  lack  of  control  over  the  bowels  when  loose,  during  the  months 
following  a  labor,  leads  us  to  expect  to  find  injury  of  the  sphincter 
ani,  also  inability  to  control  the  urine  when  standing,  or  on  laugh- 
ing and  coughing,  make  us  look  for  injury  of  the  vaginal  wall  and 
perineum  and  dislocation  downward  of  the  urethra. 

Injury  of  the  pelvic  floor  is  present  if  the  patient  complains  of 
the  noisy  escape  of  air  from  the  vagina  when  she  suddenly  changes 
the  position  of  her  body,  or  strains. 

Constitutional  Diseases. — All  general  constitutional  diseases  have 
a  bearing  both  as  causative  agents  and  aggravating  influences  on 
pelvic  disorders;  therefore  they  should  be  inquired  into  in  getting 


MENSTRUATION  13 

the  history.  It  so  often  happens  that  a  woman  in  her  usual  good 
health  is  not  seriously  incommoded  by  a  pelvic  lesion  and  when 
pulled  down  by  a  long  illness  is  overwhelmed  by  uterine  symptoms. 
The  physician  should  move  slowly  in  drawing  conclusions  as  to 
cause  and  effect,  and  also  in  judging  of  the  weight  to  be  attached 
to  the  uterine  disease. 

It  should  never  be  forgotten  that  the  whole  is  greater  than  any 
one  part  and  that  general  constitutional  diseases  take  precedence 
over  gynecological  affections.  It  is  the  sick  woman  we  are  to  treat. 

Chief  Complaint  and  Present  Illness. — It  is  very  easy  for  the  en- 
thusiastic specialist  to  bend  his  energies  to  the  making  of  a  new 
ostium  to  a  diseased  Fallopian  tube,  or  to  the  resection  of  a  diseased 
ovary,  quite  forgetting  for  what  the  patient  consulted  him;  that 
because  he  has  found  an  abnormality  of  the  pelvic  organs,  this 
must  of  necessity  be  the  cause  of  the  symptoms.  He  loses  sight  of 
the  symptoms  and  doesn't  always  make  a  proper  effort  to  relieve 
them,  being  led  away  on  a  futile  hunt  for  anatomical  perfection. 
Note,  then,  your  patient's  chief  complaint,  and  when  you  have 
finished  with  the  case,  turn  to  your  notes,  refresh  your  memory, 
and  see  whether  this  complaint  has  been  relieved. 

The  duration  and  character  of  the  present  symptoms  should  be 
noted,  such  as  pain,  leucorrhea,  abdominal  swelling,  and  symptoms 
relating  to  the  bowels  or  bladder,  and  do  not  slight  the  indications 
of  the  state  of  the  general  health  as  shown  by  the  amount  and 
character  of  the  sleep,  the  state  of  the  digestion,  and  the  strength  to 
accomplish  customary  daily  tasks. 

Menstruation. — Menstruation  may  be  defined  as  a  discharge  of 
bloody  fluid  which  takes  place  from  the  uterus  at  stated  periods 
throughout  the  time  of  sexual  activity  in  the  life  of  women.  The 
causation  of  the  discharge  is  still  in  doubt. 

Frankel  (''Die  Function  dcs  Corpus  luteum,"  Archiv  filr  Gyn., 
LXVIIL,  1903,  438)  considers  that  the  corpus  luteum  in  the  ovary 
has  a  determining  influence  on  menstruation.  It  is  plain  that  the 
ovaries  have  something  to  do  with  this  function  because,  when  they 
are  removed,  menstruation  ceases.  As  menstruation  occurs  only 
in  human  beings  and  some  of  the  higher  apes,  it  is  difficult  to  settle 
the  relation  of  menstruation  to  ovulation  and  to  the  normal  or 
abnormal  corpus  luteum  by  animal  experimentation. 

The  mechanism  of    menstruation  consists  of    a  diapedesis  of 


14  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

blood  through  delicate  capillaries,  newly  formed  in  a  thickened 
and  congested  endometrium,  the  vessels  for  the  arterial  supply 
being  more  capacious  than  those  for  the  venous  return.  Some  of 
the  capillaries  rupture  and  the  blood  flows  out. 

The  flow  at  first  is  mucus  streaked  with  blood,  during  the  height 
of  menstruation  it  is  blood  mixed  with  a  little  mucus,  and  toward 
the  end  it  becomes  more  mucous  in  character.  Menstrual  blood 
is  dark  in  color,  alkaline  in  reaction,  and,  because  of  the  mucus  it 
contains,  docs  not  clot  unless  the  mucus  happens  to  be  deficient. 
The  mucus  renders  it  more  watery  than  ordinary  blood.  It  has 
a  peculiar  odor  given  to  it  by  the  sebaceous  glands  of  the  vulva 
which  are  especially  active  during  menstruation. 

Puberty. — The  average  age  at  which  menstruation  is  established, 
in  temperate  climates,  is  fourteen  years.  Variations  of  a  year  or 
two  from  this  type  occur  within  normal  limits.  It  occurs  earlier 
in  the  city  girl  who  is  subjected,  perhaps,  to  intimate  association 
with  the  other  sex  and  to  sexual  temptations,  than  it  does  in  the 
country  girl,  or  in  a  girl  carefully  brought  up  in  comparative  seclu- 
sion. This  rule  applies  to  the  lower  animals.  If  a  bull  is  placed 
in  the  pasture  with  a  herd  of  heifers,  heat  appears  earlier  in  the 
heifers  than  it  does  when  they  are  segregated.  In  women  of  strong 
sexual  passion  the  function  of  menstruation  is  established  earlier  and 
lasts  longer  than  common. 

The  discharge  of  ova  from  the  Graafian  follicles  of  the  ovary 
has  been  known  to  take  place  before  menstruation  is  established, 
and  it  may  continue  after  the  menopause.  The  functions  of 
menstruation  and  ovulation  are  not  directly  dependent  one  on  the 
other,  but  both  appear  to  be  governed  by  the  same  portion  of 
the  sympathetic  nervous  system.  Cases  of  precocious  menstrua- 
tion are  occasionally  reported,  and  it  has  been  known  to  occur  as 
early  as  a  few  days  after  birth.  There  are  many  cases  on  record 
of  menstruation  at  a  few7  weeks  or  months  of  age.  Development 
of  the  external  genital  organs  and  the  breasts,  increase  in  body 
size,  and  often  the  growth  of  hair  on  the  pubes  goes  with  precocious 
menstruation.  The  diagnosis  is  not  established  unless  the  loss 
of  blood  recurs  at  monthly  intervals  and  a  physical  examination 
of  the  child  shows  evidences  of  premature  development. 

It  is  unusual  for  menstruation  to  be  established  before  the  twelfth 
year.  On  the  other  hand  its  appearance  is  seldom  delayed  beyond 


MENSTRUATION  15 

the  eighteenth  year.  A  case  is  on  record,  however,  where  a  woman 
married  at  thirty-four,  menstruated  for  the  first  time  at  forty-five, 
and  bore  a  child  at  forty-six.  According  to  the  investigation  of 
Rossi-Doria,  an  Italian  physician,  who  recorded  the  data  in  over 
thirty  thousand  women,  delayed  menstruation  goes  hand  in  hand 
with  pelvic  disease.  He  found  39.21  per  cent  of  pelvic  malforma- 
tions in  women  who  had  not  menstruated  until  twenty  years  or 
over. 

The  normal  rhythm  of  menstruation  is  a  lunar  month  of  twenty- 
eight  days.  A  woman  may  enjoy  perfect  health  in  every  respect 
and  yet  vary  many  days  from  the  normal  rhythm.  Many  women 
menstruate  every  three  weeks,  others  every  five  weeks,  with  perfect 
regularity.  In  getting  a  history  of  the  menstrual  function  it  is 
necessary  to  specify  the  rhythm  of  the  flow  as  well  as  the  regularity. 
It  is  well  to  remember  also  that  some  women  are  regular  at  times 
and  irregular  at  other  times. 

The  duration  of  the  flow  is  from  four  to  seven  days.  Here  also 
a  variation  within  normal  limits  of  two  days  either  way  is  to  be 
noted.  The  greatest  amount  of  blood  is  lost  in  the  first  two  days. 
A  discharge  of  mucus  before  and  after  the  flow  is  common.  The 
average  amount  of  blood  lost  at  a  single  menstruation  is  from  four 
to  six  ounces.  It  is  impracticable  to  measure  this  exactly  and  we 
are  forced  to  resort  to  the  inexact  method  of  counting  the  number 
of  napkins  used.  As  the  napkins  vary  in  size,  are  used  to  the 
point  of  saturation  by  some  women  and  barely  stained  by  others, 
no  definite  information  can  be  obtained.  Inquiry  on  these  points, 
however,  will  give  the  physician  an  approximate  estimate  which 
should  be  recorded  in  detail  in  his  notes.  About  two  well-saturated 
napkins  a  day  may  be  considered  as  being  normal. 

Whether  menstruation  is  excessive  in  any  given  case  depends  in 
a  certain  measure  on  the  physique  of  the  patient;  a  full-blooded, 
plethoric  woman  may  menstruate  eight  or  nine  days,  using  three  or 
more  well-saturated,  large  napkins  a  day;  while  an  anemic,  thin 
woman  may  be  depressed  by  the  amount  of  blood  lost  in  a  period 
of  four  days,  using  two  napkins  a  day. 

The  character  of  the  flow  is  of  importance.  Note  clotting,  an 
acid  reaction,  a  bright  arterial  color,  and  any  change  in  odor. 

Attendant  disturbances  of  other  functions,  before,  during,  and 
after  menstruation,  such  as  nausea,  headache,  depression  of  spirits, 


16  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

variations  in  the  action  of  the  bowels  or  bladder,  are  very  commonly 
observed,  and  should  be  chronicled. 

Menstruation  is  generally  attended  with  a  greater  or  less  degree 
of  a  sense  of  fulness  and  weight  in  the  region  of  the  pelvis;  often- 
times a  certain  amount  of  pain  is  to  be  considered  as  not  abnormal. 
The  menstrual  period  is  a  time  of  instability  of  the  circulation  and 
of  the  nervous  system.  The  body  temperature  is  slightly  elevated, 
the  thyroid  gland  is  enlarged,  and  the  tonsils  and  vocal  cords  may 
be  swollen  so  as  slightly  to  impair  the  singing  voice ;  so  also,  in  some 
cases,  there  are  salivation  and  swelling  of  the  mucous  membrane 
of  the  turbinate  bones  at  this  time.  There  is  increased  vascular 
tension  and  increased  secretion  of  the  sweat  glands  and  of  the 
sebaceous  glands,  especially  those  of  the  external  genitals.  Some 
women  are  affected  by  skin  diseases  at  their  catamenia,  notably 
herpes,  or  small  macular  ecchymoses  about  the  flexures  of  the 
elbows  or  knees. 

A  rhythmical  wave  of  all  the  physiological  processes  has  been 
demonstrated  by  Yon  Ott.  The  greatest  activity  is  manifest  just 
before  the  appearance  of  the  flow,  shown  by  increase  of  muscular 
strength,  tendon  reflexes,  lung  capacity,  and  heat  production.  The 
least  activity  is  during  the  flow,  the  lowest  point  being  reached  on 
the  fourth  day.  There  is  a  slight  reaction  in  the  week  following  the 
cessation  of  the  flow,  an  intermenstrual  equilibrium  of  two  or  three 
days,  to  be  followed  by  a  gradual  rise  to  a  maximum  two  days  be- 
fore the  next  flow,  and  so  on  from  month  to  month. 

The  Menopause. — The  climacteric  or  cessation  of  the  flow  usually 
occurs  from  the  forty-fifth  to  the  fiftieth  year,  the  discharge  at 
this  time  becoming  less  and  less  in  amount  and  of  irregular  occur- 
rence, gradually  stopping  altogether  in  from  six  months  to  two 
years.  Menstruation  may  stop  short  without  any  period  of  irregu- 
larity and  there  may  be  no  disturbance  of  the  nervous  system, 
although  the  latter  is  more  common. 

If  a  woman  begins  to  menstruate  early  the  menopause  is  apt  to 
be  late,  and  vice  versa.  It  is  a  family  characteristic  sometimes  to 
have  the  menopause  early  or  late.  In  ease  of  fibroid  tumors  of  the 
uterus  the  menopause  is  commonly  delayed  until  the  fiftieth  year 
or  later,  and  in  subinvolution  and  chronic  metritis  the  menopause 
comes  late. 

Yasomotor  disturbances  are  to  be  looked  for  during  the  mcno- 


MENSTRUATION  17 

pause.  The  monthly  rhythm  which  has  existed  since  the  fourteenth 
year  is  to  be  done  away  with,  the  sexual  organs  are  to  atrophy  and 
become,  functionlcss.  If  the  woman  is  in  perfect  health  we  shall 
expect  nature  to  accomplish  the  change  gradually  as  it  was  estab- 
lished, and  without  an  upsetting  of  the  general  health.  Too  often, 
for  one  reason  or  another,  the  health  is  not  rugged,  then  ensue  hot 
flashes,  sweating,  palpitation,  headaches,  nervous  irritability,  and 
derangements  of  function  in  many  organs,  more  especially  those 
most  closely  controlled  by  the  sympathetic  nervous  system. 

It  is  a  mistake  to  consider  uterine  hemorrhage  as  a  part  of  the 
normal  menopause.  It  seldom  occurs  unless  there  is  a  definite  local 
cause  in  the  shape  of  a  fibroid  tumor,  a  cancer,  chronic  subinvolu- 
tion  with  hyperplastic  endornetritis,  misplacement  of  the  uterus, 
or  other  lesion.  These  uterine  diseases  may  have  caused  no  symp- 
toms, though  existent  for  many  years.  Search  should  always  be 
made  for  them. 

The  Atrophic  Changes  in  the  Genital  Organs  and  the  Body  Altera- 
tions of  the  Menopause. — The  changes  in  the  genital  organs  and  in 
the  body  consist  of  (a)  shrinking  of  the  uterus  in  size.  The  mus- 
cular tissue  becomes  less  thick  and  gradually  the  uterine  cavity  is 
shortened  or  even  obliterated,  the  mucosa  becoming  thinned  and 
the  glands  reduced  in  number.  The  epithelial  cells  grow  smaller 
and  lose  their  cilia.  The  vaginal  portion  of  the  cervix  shrinks  and 
does  not  project  into  the  vagina.  (6)  The  vagina  is  shortened  and 
narrowed  and  its  walls  lose  their  elasticity  and  the  mucous  mem- 
brane its  ruga\  (c)  The  ovaries  shrink  to  small  knobs  of  fibrous 
tissue,  the  Graafian  follicles  disappear,  and  the  Fallopian  tubes 
become  mere  cords,  (d)  The  fat  disappears  from  the  vulva,  the 
labia  majora  become  flabby,  and  the  mons  veneris  loses  its  prom- 
inence, (e)  The  pubic  hair  turns  gray  after  the  hair  of  the  head 
has  lost  its  color.  (/)  The  breasts  also  atrophy  and  become  flabby, 
and  (g)  the  body  weight  is  increased. 

The  menstrual  flow  may  cease  prematurely  at  an  early  age,  even 
as  early  as  the  twenty-fourth  year,  the  causes  being  general  or  local. 
As  to  the  general  causes  not  much  is  known  beyond  that  they  have 
to  do  with  the  nutritive  and  vascular  systems. 

The  local  causes  are  diseases  which  destroy  the  ovaries,  as  chronic 
infective  inflammation,  and  removal  of  the  ovaries  by  operation. 
It  is  worthy  of  remark  that  when  functionating  ovaries  have  been 


18  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

removed  the  distressing  nervous  symptoms  of  the  climacteric  are 
much  more  severe  than  when  the  menopause  occurs  with  the 
ovaries  in  place.  (The  menopause  is  discussed  fully  in  Chapter 
XXIX.) 

Vaginal  Discharge. — Any  discharge  from  the  vulva  is  popularly 
referred  to  as  leucorrhea  or  whites.  A  certain  amount  of  moisture 
is  normal  and  is  made  up  of  the  secretions  of  the  sebaceous  and 
sweat  glands  of  the  vulva,  the  lubricating  mucus  secreted  by  the 
glands  of  Bartholin  lying  in  the  posterior  portion  of  the  labia  majora, 
—most  active  during  times  of  sexual  excitement, — and  by  the 
secretions  of  the  uterus. 

The  vagina  has  no  secretion  proper  and  no  glands,  the  vaginal 
secretion,  so-called,  being  that  poured  out  of  the  uterus  together 
with  epithelium  and  bacteria  made  acid  by  a  bacterium  which 
flourishes  in  the  vagina  under  normal  conditions.  The  fluid  is 
milky  and  small  in  amount.  The  secretion  from  the  cervix  is 
tenacious,  transparent,  and  thick ;  that  from  the  cndometrium  of 
the  uterine  cavity  is  clear,  transparent,  and  thin.  Both  have  an 
alkaline  reaction. 

Skenc's  glands  at  the  orifice  of  the  urethra  also  secrete  a  mucus, 
which  is  thought  to  protect  the  meatus  urinarius  during  coitus. 
Under  normal  conditions  the  combined  discharge  should  not  soil 
the  clothing  except  just  before  and  just  after  the  menstrual 
periods,  when  all  the  secretions  are  increased  in  amount  and  may 
necessitate  wearing  a  napkin. 

Abnormal  constituents  of  the  vaginal  discharge,  such  as  pus  or 
blood,  should  be  noted,  also  a  bad  odor  or  irritating  qualities.  (This 
subject  is  discussed  at  greater  length  in  Chapter  X.,  page  143.) 

Pain. — Pain  in  gynecological  affections  is  generally  situated  in 
the  inguinal  and  lumbro-sacral  regions. 

Backache. — Backache  is  not  characteristic  of  any  special  uterine 
disease  and  it  may  have  no  relation  at  all  to  the  pelvic  contents. 
All  we  can  say  is  that  it  is  very  often  present  in  women  suffering 
with  gynecological  diseases.  Backache  is  very  common  in  women 
between  the  ages  of  thirty  and  fifty  who  are  in  a  nervously  run- 
down condition.  One  sort  of  backache  due  to  sacro-iliac  sub- 
luxation  as  described  by  Joel  E.  Goldthwait  (Boston  Med.  and 
Surg.  Journal,  190"),  Vol.  152,  593)  must  be  differentiated  from 
rheumatism  of  the  muscles  in  the  lumbo-sacral  regions.  The  sacro- 


PAIN  19 

iliac  articulations  are  true  joints  and  there  is  increased  mobility 
in  them  as  well  as  in  the  symphysis  pubis  in  women  during  preg- 
nancy and  during  menstruation.  In  certain  women,  especially 
those  having  spinal  curvature  who  are  the  victims  of  subluxation, 
only  one  sacro-iliac  joint  is  tender  to  pressure,  and  the  displace- 
ment is  the  cause  of  backache  as  well  as  referred  pains  in  the  hip, 
leg,  and  ankle  on  the  same  side  as  the  loose  joint,  caused  by 
pressure  on  the  sciatic  nerve.  These  symptoms  are  not  limited  to 
the  time  of  pregnancy  and  labor,  though  exaggerated  then.  The 
symphysis  pubis  is  generally  a  loose  joint  also  in  these  cases  and 
may  be  painful  to  the  touch,  especially  during  menstruation.  The 
mobility  and  tenderness  of  all  three  joints  should  be  tested  in  any 
case  of  backache. 

Muscular  rheumatism  is  detected  by  tenderness  on  pressure  of 
the  following  muscles:— the  erector  spinse, — the  longissimus,— 
the  sacro-lumbalis,  or  the  quadratus, — and  by  pain  caused  by  the 
use  of  any  of  these  muscles.  When  a  patient  with  lumbo-sacral 
rheumatism  starts  to  straighten  up,  there  is  great  pain,  which 
abates  after  a  few  minutes'  use.  A  patient  with  this  affection  sits 
or  lies  preferably  with  the  body  bent  forward. 

Coccygodynia  is  a  painful  affection  of  the  coccyx  and  is  charac- 
terized by  pain  between  the  folds  of  the  buttocks  and  by  tenderness 
on  pressure  applied  to  the  tip  of  the  coccyx.  (See  page  159.) 

Pain  in  the  groins  is  common  in  uterine  diseases.  In  acute 
pelvic  inflammation  it  is  generally  pronounced,  especially  when  the 
peritoneum  is  involved.  In  chronic  uterine  disease  it  may,  or  it 
may  not,  be  present.  If  existent  it  is  generally  a  dull,  continuous 
pain.  If  on  the  right  side  it  is  to  be  differentiated  from  the  sharp 
intermittent  pain  of  appendicitis,  and  the  pain  and  tenderness  on 
deep  pressure  in  this  situation,  in  cases  of  uterine  disease,  are,  as  a 
rule,  lower  down  than  in  appendicitis. 

A  bearing-down  feeling,  or  a  sense  of  weight  in  the  pelvis,  is  a  very 
frequent  complaint.  If,  in  answer  to  your  question,  the  patient 
states  that  she  has  pain,  ascertain  where  it  is  situated;  the  point 
of  greatest  intensity;  whether  it  is  constant  or  intermittent,  fixed 
or  radiating;  what  sort  of  a  pain,  dull,  sharp,  or  stabbing.  Describe 
it  in  the  patient's  own  words  as  far  as  possible.  The  relation  be- 
tween the  pain  and  menstruation,  if  any,  should  be  inquired  into; 
also  the  effect  of  exercise.  The  situation  of  the  pain  often  shows 


20  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

the  nature  of  the  lesion.  Thus,  pain  in  the  sacral  region  may  mean 
rectal  disease,  and  pain  above  the  pubes,  disease  of  the  bladder. 
This  is  not  always  the  case,  as  is  shown  by  the  fact  that  disease  of 
one  ovary  is  often  referred  to  the  opposite  side  of  the  abdomen, 
therefore  we  must  be  on  the  lookout  for  referred  pain. 

Abdominal  swelling,  indicating  a  tumor  of  any  sort,  is  to  be  asked 
for.  If  present,  when  was  it  first  noticed, — what  is  its  exact  situa- 
tion,— has  it  increased  in  size  since  it  was  first  detected,  and  if  so 
how  much  and  how  fast, — whether  or  no  there  has  been  pain  in  the 
swelling  or  tenderness  on  pressure. 

In  the  case  of  a  suspected  ovarian  tumor,  ask  whether  there  has 
been  a  loss  of  flesh  about  the  chest  and  shoulders  coincident  with 
the  increase  in  the  size  of  the  abdomen.  The  occurrence  of  jaundice 
in  connection  with  a  tumor  in  the  upper  abdomen,  as  indicating 
disease  of  the  liver  or  gall-bladder,  is  to  be  noted,  also  the  relation 
between  a  tumor  in  the  flank  and  impaired  function  of  the  kidneys, 
pointing  toward  tumor  of  the  kidney. 

A  swelling  of  the  abdomen  in  a  woman  of  child-bearing  age  may 
mean  pregnancy,  however  improbable  such  a  diagnosis  may  seem, 
—therefore  ask  always  the  date  of  the  last  menstruation.  Bear 
pregnancy  in  mind  even  if  the  probable  diagnosis  is  fibroid, 
ovarian  cyst,  or  other  tumor:  pregnancy,  intra-  or  extrauterine, 
may  coexist  as  a  complicating  condition.  It  has  happened 
several  times  in  the  author's  experience  that  a  surgeon  of  high 
reputation  has  discovered  pregnancy  in  the  course  of  an  abdom- 
inal operation,  undertaken  for  "abdominal  tumor"  without  a 
more  exact  diagnosis. 

Bladder  Symptoms. — The  fact  should  be  borne  in  mind  that 
women,  as  a  rule,  urinate  at  less  frequent  intervals  than  men.  In 
obtaining  a  history  it  is  important  to  inquire  as  to  the  patient's 
habit  as  regards  micturition,  before  drawing  conclusions  as  to  the 
abnormality  of  the  symptoms.  The  occurrence  of  bladder  affec- 
tions is  rarer  in  women  than  in  men. 

Frequency  of  urination  on  standing  or  exertion,  with  inability 
to  hold  the  urine,  may  mean  a  stone  in  the  bladder,  whereas  constant 
desire  to  urinate  may  be  due  to  cystitis  or  urethritis;  therefore  it  is 
necessary  to  inquire  whether  the  frequency  is  by  day  or  by  night. 
Smarting  on  urination  indicates  some  irritation  of  the  vulva  or 
urethra.  Inabilitv  to  control  the  urine  at  all  shows  a  fistula  from 


THE  BOWELS  21 

the  bladder  into  the  vagina,  either  directly,  or  by  way  of  the  uterus; 
lack  of  power  over  the  bladder  on  laughing,  sneezing,  and  coughing 
means  lack  of  support  to  bladder  or  urethra  from  injury  to  the 
pelvic  floor  or  to  the  anterior  vaginal  wall.  These  are  samples  of 
the  class  of  facts  wrhich  should  be  learned.  (The  subject  is  con- 
sidered at  length  in  Chapter  X.,  page  151.)  Ask: — How  often  the 
patient  urinates?  How  frequently  at  night?  How  much  pain  in 
the  act?  When  the  pain  is  most  intense?  How  long  the  pain 
lasts?  Is  it  possible  to  control  the  urine  when  the  desire  to  urinate 
occurs?  Is  the  trouble  getting  better  or  worse?  Is  it  affected  by 
menstruation?  Is  it  better  or  worse  when  the  bowels  are  free? 
When  did  the  difficulty  begin?  What  is  the  supposable  cause?  Is 
the  trouble  the  same  now  as  at  the  beginning?  What  treatment,  if 
any,  has  been  used? 

The  Bowels. — Constipation  is  the  rule  in  a  large  proportion  of 
women  suffering  with  gynecological  affections.  At  least  a  third  of 
all  such  patients  are  so  affected,  according  to  reliable  statistics.  The 
statement,  however,  that  a  woman  is  constipated  does  not  describe 
the  condition  with  sufficient  minuteness.  Many  women  pay  little 
attention  to  their  bowels,  considering  defecation  as  a  troublesome 
function  to  be  disregarded  as  long  as  possible.  Therefore,  it  is 
necessary  to  make  careful  inquiries  to  determine  that  constipation 
really  exists.  The  amount  of  fecal  matter  passed  depends,  of  course, 
on  the  amount  arid  character  of  food  ingested.  People  of  irregular 
habits  as  regards  their  food  should  be  expected  to  pass  a  variable 
amount  of  fecal  matter;  four  to  eight  ounces  is  said  to  be  the 
normal  amount  passed  in  twenty-four  hours  if  the  patient  is  living 
on  a  mixed  diet.  The  amount  is  more  if  the  diet  is  vegetable  rather 
than  if  animal.  Habits  of  a  lifetime  have  a  controlling  influence  on 
defecation,  and  a  person  may  evacuate  the  bowels  regularly  every 
other  day  or  twice  a  day  and  yet  be  within  the  limits  of  the  normal. 
We  must  inquire  whether  the  bowels  move  regularly,  i.e.,  without 
medicine,  enema,  or  artificial  aid  of  any  kind,  at  stated  periods  of 
time,  and  what  those  times  are:  whether  the  action  is  full,  or 
scanty,  and  the  stools  solid,  semisolid,  or  liquid;  whether  there  is 
pain  on  defecation  at  the  time  (hemorrhoids)  or  lasting  after  the 
movement  (fissure  of  the  anus):  whether  the  stools  are  ribbon- 
like  (stricture  of  the  rectum):  whether  offensive  (decomposition); 
containing  blood,  mucus,  or  pus  (hemorrhoids  or  fistula  in  ano); 


22  INTERPRETATION  OF  THE  CLINICAL  HISTORY 

whether  there  is  escape  of  gas  involuntarily  (some  injury  of  the 
sphincter,  or  fistula  in  ano). 

In  some  cases  of  injury  of  the  pelvic  floor  the  patient  finds  that 
the  only  way  she  can  evacuate  the  rectum  is  by  making  digital 
pressure  in  the  vagina.  Prolapse  of  the  rectum  on  straining  at 
stool  is  to  be  borne  in  mind  in  getting  the  history. 

Inquiry  should  be  made  as  to  the  length  of  time  constipation  has 
existed,  whether  it  is  habitual  or  intermittent,  and  whether,  in  the 
patient's  mind,  there  is  any  assignable  cause.  The  physician  should 
consider  a  pelvic  tumor,  rupture  of  the  pelvic  floor,  a  stricture,  or 
malignant  disease  of  the  intestine  as  possible  causes  of  constipation. 
(See  Chapter  X.,  page  156.) 

Present  Illness. — Under  this  heading  we  group  together  the 
symptoms  which  go  to  make  up  the  complaint  for  which  the  patient 
consults  the  physician.  They  consist  of  the  data  as  to  the  functions 
of  the  different  organs.  Appetite,  digestion,  and  sleep  receive  con- 
sideration in  the  detail  justified  by  their  importance  in  any  given 
case,  also  any  symptoms  indicating  derangement  of  the  heart, 
lungs,  kidneys,  or  other  organs. 

Variations  in  the  body  weight  are  important  as  showing  changes 
in  the  nutrition.  Other  things  being  equal,  a  greater  weight  shows 
increased  vigor  and  strength:  such  a  statement  being  susceptible 
of  modification  in  the  case  of  very  fat  people. 

In  this  portion  of  the  history  the  physician  has  an  opportunity 
to  show  his  ability  as  an  internist  and  by  his  knowledge  of  the 
science  and  art  of  medicine  to  keep  his  patient,  if  possible,  on  the 
main  line  of  practice  instead  of  shunting  her  on  to  the  sidetrack  of 
specialism. 

It  is  always  wise  to  note  the  exact  date  of  the  last  menstruation 
before  finishing  the  history.  A  habit  of  doing  this  will  go  a  long 
way  toward  preventing  awkward  mistakes. 

Finally,  as  a  matter  of  record,  make  a  memorandum  of  the 
patient's  peculiarities  of  form  and  figure. 


CHAPTER  IV 

THE  PHYSICAL  EXAMINATION 

I.  The  preparation  of  the  patient,  p.  23. 

II.  The  preparation  of  the  examining  table,  p.  26.     Care  of  the  instru- 
ments, with  list  of  a  full  kit,  p.  28. 

III.  The  examination:     1.  Preparation  of  the  physician  and  placing  the 
patient  on  the  table,   p.   31;   The  dorsal  position,   p.  33.     2.  Inspection  of 
the  external  genitals,  p.  33.     3.  Palpation,  p.  34:    (a)  The  vaginal  touch, 
p.  34;  (6)  The  combined  vaginal  and  abdominal  touch,  p.  38. 

HAVING  taken  the  history  as  outlined  in  the  preceding  chapter, 
the  next  procedure  is  the  physical  examination.  It  is  not  neces- 
sary to  follow  exactly  the  same  routine  in  all  cases;  nevertheless 
it  is  most  essential  to  have  a  definite  system  and  to  proceed  accord- 
ing to  it  in  all  but  exceptional  instances,  because  in  this  way,  and 
in  this  way  onhr,  are  sources  of  error,  the  omission  of  important 
signs,  reduced  to  a  minimum. 

First  let  us  consider  I.  the  preparation  of  the  patient,  then  II.  the 
preparation  of  tlie  examining  table  and  the  instruments,  and  lastly 
III.  the  examination  itself. 

So  much  does  a  good  diagnosis  depend  on  careful  preliminaries 
and  on  a  multitude  of  little  things  that  no  apology  is  necessary  for 
the  space  devoted  to  them.  . 

I.  THE  PREPARATION  OF  THE  PATIENT 

It  is  absolutely  essential  that  the  rectum  should  be  empty  in 
order  that  the  physician  may  make  a  satisfactory  bimanual  ex- 
amination, also,  in  the  case  of  abdominal  palpation,  if  the  bowels 
are  distended  by  feces  or  gas  the  ability  of  the  examiner  to  appre- 
ciate the  condition  of  the  abdominal  contents  will  be  interfered 
with.  Therefore  the  patient,  if  there  is  need  and  if  time  serves, 
should  be  instructed  to  take  a  cathartic  the  day  before  the  exam- 
ination or  an  enema  immediately  before. 

23 


24  PHYSICAL  EXAMINATION 

If  a  patient  presents  herself  with  the  statement  that  the 
bowels  have  not  moved  for  several  clays  it  is  better  not  to 
make  an  examination  until  they  are  solvent,  except  in  cases  of 
emergency. 

Unless  there  is  some  suspicion  of  disease  of  the  urinary  organs 
the  bladder  is  to  be  emptied  just  before  the  examination.  In 
certain  urinary  cases,  where  it  is  desired  to  obtain  a  catheter  speci- 
men of  urine  at  the  examination,  the  patient  should  be  asked  not 
to  empty  her  bladder  before  the  examination. 

As  a  rule  it  is  better  to  have  no  douche  or  special  wash  given 
before  the  examination,  because  the  examiner  wishes  to  form  an 
opinion  as  to  the  character  of  the  discharge,  if  present.  It  is  a 
simple  matter  for  him  to  wipe  away  the  discharge  later  with  sterile 
cotton  or  some  antiseptic  solution. 

The  most  important  matter  in  connection  with  the  preparatory 
treatment  of  the  patient  and  the  one  most  often  overlooked  is  the 
loosening  of  all  constricting  clothing  about  the  waist.  Simply  to 
loosen  the  corsets  and  leave  the  drawers  buttoned  about  the  waist 
is  not  sufficient.  So  often  women  come  to  the  examining  table 
with  corsets  and  skirts  loosened,  and  investigation  reveals  one  or 
two  tight,  constricting  bands  still  left.  Closed  drawers  should  be 
removed.  The  union  suit  is  a  foe  to  an  accurate  diagnosis  and 
should  be  removed.  If  the  patient  considers  her  condition  of 
ill  health  important  enough  to  consult  a  physician  she  should  be 
ready  to  offer  no  hindrance  to  a  proper  examination. 

With  any  encircling  girdle  about  the  upper  abdomen  it  is  mani- 
festly impossible  to  compress  the  abdominal  walls  and  to  palpate 
the  contents  of  the  abdomen  and  pelvis.  Such  palpation  is  difficult 
enough  with  all  conditions  favorable,  therefore  do  not  handicap 
it  by  omitting  to  have  all  clothing  loosened. 

If  the  patient  is  in  bed  she  should  be  prepared  by  having  her 
put  on  a  fresh  pair  of  stockings.  Should  the  Sims  position  be 
used  an  extra  towel  will  serve1  for  covering  the  right  thigh. 

Much  depends  on  the  physician's  tact  and  the  manner  in  which 
he  goes  about  the  preparation  for  the  physical  investigation. 
Women  do  not  mind  an  examination  which  they  consider  necessary 
if  the  physician  shows  proper  consideration  for  their  feelings  and 
knows  how  to  go  about  the  examination.  If  the  matter  is  treated 
as  disagreeable  and  to  be  put  through  as  quickly  as  possible,  the 


PREPARATION  OF  THE  PATIENT  25 

result  is  apt  to  be  that  the  physician's  frame  of  mind  will  be  re- 
flected in  the  patient  and  she  will  be  ill  at  ease  and  consequently 
will  not  give  herself  up  to  the  investigation,  not  relaxing  the  ab- 
dominal muscles  and  thus  limiting  the  facts  which  may  be  gleaned 
through  the  tactile  sense. 

The  patient  should  be  made  to  feel  that  the  examination  is  to 
be  conducted  with  as  little  pain  and  discomfort  as  is  possible  and 
that  this  is  an  important  consideration  to  the  examiner.  She  may 
be  told  a  fact  too  often  lost  sight  of,  that  pain,  caused  by  roughness 
or  vigorous  handling,  makes  unconscious  resistance  and  rigidity 
of  the  abdominal  muscles,  thereby  dulling  the  sense  of  touch  in 
the  doctor's  hands  and  preventing  him  from  reaching  deep-lying 
structures — consequently  the  examination  is  less  successful. 
Often  it  is  inadvisable  to  make  a  thorough  investigation  and  a 
complete  diagnosis  at  one  sitting.  Sometimes  it  is  necessary  to 
examine  the  patient  on  several  different  occasions  before  all  the 
conditions  have  been  found  favorable  and  all  the  facts  have  been 
brought  out.  Therefore  do  not  be  led  to  express  an  opinion  on 
the  case  prematurely. 

In  the  case  of  young  girls  it  is  generally  advisable  to  use  an 
anesthetic  before  making  a  local  examination,  although  it  is  not 
always  necessary,  much  depending  on  the  nervous  temperament 
of  the  patient.  In  making  an  examination  of  a  virgin  in  whom 
menstruation  has  been  established  an  anesthetic  is  seldom  required 
if  great  tact  and  gentleness  are  used.  It  is  far  preferable  to  make 
the  first  examination  without  ether  if  possible,  because  often  facts 
of  importance,  such  as  regions  of  tenderness,  brought  out  during 
the  examination,  are  lost  in  an  ether  examination,  to  say  nothing 
of  the  unfavorable  after-effects  of  the  anesthetic  on  the  patient. 
Should  the  first  investigation  show  the  need,  another  examination 
with  ether  can  be  made. 

Too  much  can  not  be  said  of  the  importance  of  the  tactful  hand- 
ling of  the  patient  previous  to  the  examination.  To  see  one  skilled 
nurse  in  a  large  hospital  clinic  put  forty  women  on  the  table  for 
examination  during  the  course  of  an  afternoon,  no  complaints,  no 
objections,  and  one  following  the  other  with  military  precision, 
is  an  object  lesson  of  no  mean  value.  Few  nurses  acquire  such 
expertness,  and  to  few  is  it  needful.  Much  may  be  learned  by 
studying,  when  the  opportunity  offers,  the  way  it  is  done. 


20  PHYSICAL  EXAMINATION 

The  local  examination  should  he  made  during  the  intermenstrual 
period.  Only  in  the  ease  of  hemorrhage  and  unusual  conditions 
is  it  necessary  to  examine  during  menstruation. 


II.   THE  PREPARATION  OF  THE  EXAMINING  TABLE  AND 
THE  INSTRUMENTS 

Some  hard  surface  on  which  the  patient  is  to  lie  is  a  necessity 
for  a  proper  examination.  A  soft  bed  or  couch  into  which  she 
sinks  takes  away  all  space  under  the  buttocks  for  the  unused  fingers 
of  the  examiner's  hand  in  the  vaginal  examination.  Besides,  most 
beds  and  couches  are  so  low  that  the  physician  is  in  an  uncom- 
fortable position  while  examining  and  so  many  of  his  muscles  are 
tense  that  he  can  not  concentrate  his  entire  attention  on  what  his 
fingers  are  feeling.  Furthermore,  with  the  patient  on  a  low  couch 
the  physician  can  not  get  his  eyes  on  a  low  enough  level  to  look  into 
the  vagina  unless  he  sits  on  the  floor  in  an  awkward  and  constrained 
position. 

A  table,  the  size,  shape,  and  height  of  an  ordinary  kitchen  table, 
is  on  the  whole  the  best  surface  on  which  to  put  the  patient.  Port- 
able or  fixed  supports  for  the  feet  are  a  useful  addition  and  also  a 
movable  slide  projecting  from  the  right-hand  lower  corner  of  the 
table  is  a  convenient  adjunct.  My  table  is  stoutly  built  of  walnut, 
has  large  casters  on  all  four  feet,  and  is  of  the  following  dimensions: 
—Length,  44  inches;  breadth,  24  inches:  height  at  bottom  end, 
33  inches;  height  at  head  end,  31  inches. 

It  is  to  be  noted  that  the  foot  or  examining  end  is  higher  than 
the  head  end.  This  is  to  cause  the  viscera  to  gravitate  away  from 
the  pelvis  and  to  allow  of  more  pillows  for  the  head  without  in- 
clining the  trunk  downward  toward  the  pelvis. 

The  table  is  covered  with  a  hair  pillow  one  inch  thick,  encased 
in  a  dark-colored,  enameled  canvas  cover.  This  cover  is  buttoned 
to  the  under  edge  of  the  table  top,  as  the  removable  sides  of  a 
carriage  are  fastened  on. 

Fixed  or  portable  rests  for  the  feet  are  an  advantage,  because 
with  the  feet  slightly  elevated  above  the  surface  of  the  table  and 
at  a  short  distance  beyond  the  table's  edge  the  abdominal  muscles 
are  more  thoroughly  relaxed  and  the  patient  is  more  comfortable 


PREPARATION  OF  TABLE  AND  INSTRUMENTS  27 

than  she  is  with  heels  close  to  the  buttocks,  and  slipping  off  the 
table. 

In  private  houses  the  kitchen  table  is  always  available  or,  if  it 
is  best  in  occasional  instances  to  examine  the  patient  in  bed,  an 
ironing  board  or  bread  board  may  be  placed  on  the  mattress  under 
the  patient's  hips,  which  should  be  at  the  edge  of  the  bed,  the  feet 
resting  in  two  chairs.  A  folded  blanket,  or  two  thicknesses  of  a 
comforter,  should  be  laid  on  the  table  or  board  to  take  away  the 
hardness.  In  this  way  the  patient  is  reasonably  comfortable  during 


FIG.   1. — The  Examining  Table. 

the  short  time  occupied  by  the  examination  and  the  physician  can 
do  his  work  to  the  best  advantage. 

There  are  few  points  of  superiority  and  many  disadvantages 
in  the  complicated  and  costly  tables  sold  in  the  instrument  shops. 
The  patient  is  not  at  ease  on  an  unstable  surface  and  she  does  not 
like  to  feel  that  by  the  pressure  of  levers  she  may  be  tilted  into  all 
sorts  of  positions ;  she  is  not  in  a  state  of  mind  to  appreciate  the 
beauty  of  the  ingenious  mechanism  concealed  in  the  table,  and 
would  rather  lie  on  a  solid,  warm  wooden  table  than  on  a  hard, 
cold  one,  made  of  glass  and  iron. 


12S  PHYSICAL  EXAMINATION 

The  ordinary  vaginal  examination  need  not  be  a  strictly  aseptic 
operation,  and  it  calls  for  clean,  not  aseptic  furniture. 

Suppose  we  have  the  table  placed  with  its  end  toward  a  good 
light.  \Ye  cover  it  with  a  folded  comforter  and  a  sheet,  unless  it 
is  already  provided  with  a  permanent  cushion.  When  the  patient 
lies  on  her  back  with  hips  and  heels  at  the  edge,  the  only  portion 
of  the  table  which  will  come  in  contact  with  the  region  about  the 
vulva  and  anus  is  a  narrow  part  of  the  middle  of  the  end,  some 
two  inches  wide  and  six  inches  long.  Therefore  for  every  patient 
a  fresh  towel  is  opened  just  as  it  comes  from  the  laundry  and  a 
newspaper  is  folded  into  it  so  that  the  original  folds  of  the  towel 
are  reproduced.  This  towel,  about  six  inches  wide  and  a  foot 
long,  is  now  placed  in  the  middle  of  the  examining  end  of  the 
table  and  one  end  tucked  under  the  comforter  or  cushion.  The 
surface  to  sit  upon  is  thus  some  six  by  nine  inches,  according  to 
the  size  of  the  towel.  In  this  way  each  patient  sits  on  an  abso- 
lutely fresh  towel,  and  the  table  is  protected  from  the  vaginal 
discharges  or  solutions  used  by  the  physician,  by  the  newspaper 
which  has  been  folded  into  the  towel. 

It  is  seldom  necessary  to  soil  the  sheet  or  cushion.  If  by  any 
chance  it  is  soiled,  as  in  case  of  hemorrhage,  the  sheet  or  towel 
is  removed  and  the  enameled  canvas  surface  of  the  cushion  is 
washed  and  a  fresh  sheet  or  towel  put  on.  A  pillow  for  the  pa- 
tient's head  is  placed  at  the  head  end  of  the  table. 

CARK  OF  THE  IXSTRUMF.XTS 

Very  few  instruments  are  necessary  for  the  routine  gynecological 
examination.  A  uterine  dressing  forceps,  a  sound,  and  a  small- 
sized  bivalve1  speculum  are  frequently  all  that  will  be  required. 

It  is  best  to  keep  all  instruments  out  of  the  patient's  sight, 
because  she  does  not  admire  them  nor  look  at  them  from  the  same 
point  of  view  as  the  doctor,  and  it  is  not  at  all  reassuring  to  feel  that 
all  the  bright  instruments  of  seeming  torture  may  be  used  on  her. 

My  full  kit  contains  the  following  instruments: 

Flexible'  uterine  sound: 

Uterine  probe; 

Bozeman  uterine  dressing  forceps; 

Uterine  tenaculum.  single; 


PREPARATION  OF  TABLE  AND   INSTRUMENTS  29 

Uterine  tenaculum,  double,  or  vulsellum; 

Uterine  scissors; 

Silver  uterine  probe ; 

Small-size  Brewer  bivalve  speculum; 

Graves  bivalve  speculum; 

Smallest  size  Sims  speculum,  also  No.  4  size; 

Edebohls  speculum  (included  in  the  kit  for  cases  in  which 
curetting  or  removal  of  a  piece  of  tissue  is  necessary  for  diagnosis) ; 

Hunter  vaginal  depressor; 

Emmet  curette  forceps; 

Bozeman-Fritsch  uterine  douche; 

Two  uterine  applicators; 

Uterine  sharp  curette  with  flexible  shaft; 

Set  of  Hanks  metal  uterine  dilators; 

Wart  hen  uterine  dilator; 

Silver  female  catheter; 

Kelly  meatus  calibrator; 

Set  of  Kelly  double-ended  steel  urethral  sounds; 

Kelly  cystoscopes,  Nos.  8,  10,  12; 

Alligator  bladder  forceps; 

Two  Kelly  ureteral  catheters; 

Kelly  proctoscopes,  two  sizes; 

Kelly  ureteral  searcher,  and  rubber  bulb  and  tube  for  suction; 

Head  mirror; 

Stethoscope ; 

Pelvimeter. 

Added  to  these  are: 

Two  sterile  two-ounce  bottles; 

Compressed  tablets  of  cocaine  hydrochlorate; 

Sterile  absorbent  cotton ; 

Sterile  gauze; 

A  bottle  of  creolin: 

Cover  glasses. 

A  collapsible  tube  of  a  sterile,  soluble  lubricant  sold  under  the 
names  of  Lubrichondrhi,  Glycerine  Emollient,  Muco,  or  K-Y 
Jelly. 

It  is  my  practice  to  have  one  set  of  instruments  in  a  drawer 
within  easy  reach  of  my  right  hand  as  I  sit  in  front  of  my  examin- 


30  PHYSICAL  EXAMINATION 

ing  table;  another  set  is  in  a  bag  ready  to  be  carried  to  consulta- 
tions at  the  patients'  homes. 

After  use  the  instruments  are  scrubbed  with  soap,  hot  water,  and 
a  nail  brush,  rinsed  with  boiling  water,  dried  at  once,  and  put  away 
clean.  In  cancer  cases  and  those  in  which  infectious  matter  is 
pretty  surely  present  the  instruments  are  boiled  in  soda  as  well  as 
scrubbed  with  soap  and  water  before  being  put  away.  Before  use, 
the  instruments  which  it  is  thought  will  be  used,  are  placed  in  a 
shallow  enameled  iron  tray  and  boiled  for  five  minutes  in  a  one- 
per-cent  solution  of  washing  soda  in  water;  the  soda  solution  is  then 
poured  off  and  hot  water  substituted.  No  instruments  are  ever  let 
lie  for  any  length  of  time  after  use  without  being  washed.  Until 
cleansed  they  are  always  kept  immersed  in  water  so  that  discharges 
and  blood  can  not  dry  on. 


III.   THE   EXAMINATION 

1.  Preparation  of  the  physician  and  placing  the  patient  on  the 
table. 

2.  Inspection  of  the  external  genitals. 

3.  Palpation:  (a)  The  vaginal  touch.     Dorsal  position. 

(6)  The  combined  bimanual  vaginal  and  abdom- 
inal touch,  including  points  hi  the  anatomy 
and  the  findings  on  palpation. 

(c)  The  rectal  touch. 

(d)  The  bimanual  recto-abdominal  touch. 

(e)  Positions  of  the  patient  used  in  gynecological 

examinations  other  than  the  dorsal;  the 
Sims  position;  the  knee-chest  position;  the 
lithotomy  position;  the  raised  pelvis  posi- 
tion; the  standing  position. 

4.  Odor  as  a  diagnostic  sign. 

o.  The  collection  of  the  discharges  and  tissues  for  bacteriological 
examination. 

6.  Inspection  of  the  abdomen. 

7.  Palpation  of  the  abdomen. 

8.  Percussion,  auscultation,  and  mensuration  of  the  abdomen. 

9.  Instruments  and  their  use  in  diagnosis. 


THE  EXAMINATION 


31 


1.  PREPARATION  OF  THE  PHYSICIAN  AND  PLACING  THE  PATIENT 

ON  THE  TABLE 

The  physician  prepares  himself  by  washing  his  hands 
carefully  and  if  they  are  cold  by  warming  them,  and  by 
pulling  up  the  sleeves  of  his  coat  and  his  cuffs  so  that  they 
will  not  come  in  contact  with  the  patient.  As  to  rubber  cots 
and  rubber  gloves,  they  interfere  with  the  tactile  sense,  how- 
ever used,  and  should  be  employed  only  in  exceptional  in- 
stances, as  in  cases  of  suspected  gonorrhea  and  of  fetid  dis- 
charge, also  in  rectal  examinations.  They  serve  to  protect 


FIG.  2. — The  Examining  Hand,  Showing  Protective  Sleeve. 

coming  patients  and  also  the  physician  from  contamination,  as 
inoculation  with  syphilis,  and  favor  the  cause  of  asepsis.  The 
physician  who  is  personally  neat  and  washes  his  hands  care- 
fully before  as  well  as  after  a  vaginal  examination,  need  have 
no  fear  of  carrying  bacteria  from  patient  to  patient.  The 
examination  can  not  be  so  well  made  with  cots  or  gloves  as  without 
them,  therefore  do  not  use  them  unless  necessary. 

As  to  protecting  the  sleeves,  it  is  a  good  plan  to  wear  sleeves 
made  of  "Stork  sheeting"  or  thin  rubber,  with  elastics  at 
the  wrists  and  elbows,  pulled  on  over  the  coat  sleeves.  These 
rubber  sleeves  can  be  frequently  cleansed  and  they  prevent 
carrying  infection  from  one  patient  to  another.  They  obviate 
the  necessity  of  removing  the  coat,  a  procedure  which  is  undesir- 


32 


PHYSICAL   EXAMINATION 


able  because  it  seems  to  indicate  to  the  patient  formidable  un- 
dertakings. 

Of  the  importance  of  washing  the  hands  before  the  examination 
too  much  can  not  be  said.  One  never  knows  what  bacteria  he 
may  have  on  his  hands  and  under  his  finger  nails.  Every  one 
necessarily  washes  his  hands  after  the  examination;  how  much 
more  essential,  from  the  standpoint  of  the  patient's  safety,  is  the 
preliminary  wash.  lie  who  would  practice  gynecology  must  have 
the  hand  washing  habit. 

It  is  my  custom  to  prepare  a  basin  full  of  warm  creolin  solution, 


FIG    3. — The  Dorsal  Position. 

one  per  cent,  and  place  it  on  the  instrument  table  within  reach  of 
my  right  hand.  As  before1  stated,  the  examination  is  not  and  need 
not  be  a  strictly  aseptic  operation;  therefore  some  antiseptic,  which 
does  not  coagulate  the  albumen  of  the  discharges,  has  an  odor  of 
its  own,  does  not  corrode  instruments,  nor  irritate  the  tissues,  is 
indicated.  Any  table  will  serve  on  which  to  lay  the  pan  of  instru- 
ments, basin,  and  sterile  cotton.  A  low  table  is  preferable  to  a 
high  one.  Its  surface  should  be  covered  with  a  fresh  towel. 
The  usual  position  employed  in  gynecological  examinations  is 


INSPECTION    OF    EXTERNAL    GENITALS  33 

the  dorsal  position.  The  Sims  position,  the  knee-chest  position, 
the  elevated  pelvis  position,  the  lithotomy  position,  and  the  stand- 
ing position  will  be  described  later. 

The  Dorsal  Position. — Everything  being  in  readiness,  the  patient 
steps  into  a  hard-bottomed  chair  placed  at  the  foot  of  the  table 
and  raises  all  her  skirts  behind,  the  physician  meanwhile  standing 
in  front  of  her  and  holding  up  a  sheet,  so  that  she  is  screened  from 
him  as  she  sits  on  the  little  folded  towel  on  the  edge  of  the  table. 
She  lies  down  and  puts  her  feet  in  the  supports.  To  prevent 
straining  the  back  it  is  well  to  ask  the  patient  to  draw  up  her  knees 
as  she  lies  down,  otherwise  her  back  will  reach  the  cushion  while 
her  feet  are  still  in  the  chair,  putting  her  into  a  sort  of  Walcher 
position,  one  of  great  discomfort. 

The  sheet  is  now  thrown  over  the  recumbent  woman  so  that 
she  is  entirely  covered.  Holding  the  lower  edge  of  the  sheet  in 
the  left  hand  the  physician  raises  the  patient's  skirts  in  front  with 
his  right  hand  under  the  sheet.  Then  by  carrying  the  middle  point 
of  the  sheet  upward  to  the  pubic  region  both  thighs  are  draped  and 
only  the  vulva  and  anal  regions  are  exposed.  A  woman  does  not 
object  to  an  exposure  of  the  genitals  that  is  manifestly  necessary 
so  long  as  the  surrounding  parts  and  the  body  are  covered  up. 
This  method  of  covering  with  the  sheet  is  applicable  to  every  sort 
of  a  case,  and  should  be  employed  always  unless  the  patient  is 
anesthetized. 

If  the  examination  is  at  the  patient's  home  the  table  is  prepared 
in  a  good  light  in  her  room  and  she  either  walks  to  the  examining 
table,  or,  if  unable  to  walk,  is  carried  from  the  bed. 

2.  INSPECTION  OF  THE  EXTERNAL  GENITALS 

There  is  no  valid  objection  to  an  inspection  of  the  vulvar  region; 
in  fact,  a  proper  diagnosis  can  not  be  made  without  it.  The  physi- 
cian seats  himself  in  the  chair  used  by  the  patient  to  get  upon  the 
table,  and  spreads  a  fresh  towel  over  his  knees.  By  placing  the 
fingers  of  each  hand  on  the  labia  majora  the  labia  are  drawn  gently 
apart  and  he  notes  the  condition  of  the  hymen,  whether  with  one 
or  more  openings,  unbroken  or  broken;  the  amount  and  character 
of  the  vaginal  discharge;  the  appearance  of  redness  about  the 
orifices  of  Burtholin's  glands  or  Skene's  glands. 
3 


34  PHYSICAL  EXAMINATION 

If  redness  appears  about  the  orifices  of  Skene's  glands,  the  well- 
anointed  finger  should  be  introduced  for  an  inch  into  the  vagina, 
pressing  backward  toward  the  sacrum  with  the  dorsuni  of  the 
finger  as  it  is  slipped  into  the  vagina,  and  gentle  pressure  made 
with  the  tip  of  the  finger  along  the  course  of  the  urethra  from 
above  downward  to  express  pus  from  the  glands. 

He  notes  further  the  condition  of  the  meatus  urinarius,  whether 
closed  or  open ;  the  prepuce,  whether  adherent  to  the  glans  clitoridis 
or  not,  and  injuries  of  the  perineum.  The  surface  of  the  perineum 
between  the  fourchette  and  the  anus  should  present  a  convexity; 
if  it  is  flat  or  concave  it  means  an  injury  to  the  pelvic  floor  or 
perineum. 

Palpation  is  to  be  combined  with  inspection  in  determining  the 
nature  and  extent  of  injuries  in  this  region.  (See  Chapter  XX, 
page  372.)  One  must  be  on  the  lookout  for  skin  affections.  Pedi- 
culi  are  occasionally  found  among  the  poorer  classes;  and  all  sorts 
of  anomalies  of  the  external  genitalia  are  to  be  looked  for.  In- 
spection of  the  vagina  will  be  taken  up  in  the  chapter  on  the  use 
of  instruments. 

3.  PALPATION 

Palpation  includes  the  vaginal  touch,  the  combined  bimanual 
vaginal  and  abdominal  touch,  the  rectal  touch,  and  the  combined 
bimanual  recto-abdominal  touch.  The  examination  of  the  abdo- 
men will  be  considered  in  another  chapter. 

(a)  The  Vaginal  Touch. — The  physician  has  washed  his  hands 
with  care,  his  nails  are  always  trimmed  short  and  arc  clean,  and 
his  hands  are  warm.  He  stands  facing  the  patient,  who  is  in  the 
dorsal  position  on  the  examining  table.  Now  comes  the  question 
which  hand  to  use  for  the  vagina.  I  prefer  the  left  hand  for  the 
reasons  that  the  left  hand  is  less  frequently  used  for  ordinary  pur- 
poses than  the  right;  therefore,  the  skin  covering  the  terminal 
phalanx  of  the  left  forefinger  is  softer  and  capable  of  higher  training 
of  the  tactile  sense;  less  strength  is  required  of  the  examining 
hand  at  the  vagina  than  of  the  hand  on  the  abdomen,  which  is 
engaged  in  gross  manipulations,  the  right  hand  is  usually  the 
stronger  except  in  the  case  of  left-handed  persons;  the  left  hand 
is  generally  a  trifle  more  flexible  than  the  right  hand,  an  important 


PALPATION  35 

consideration  with  reference  to  stowing  away  the  unused  fingers, 
and  finally,  using  the  left  finger  for  the  examination  leaves  free  the 
highly  trained  right  hand  for  the  delicate  manipulation  of  instru- 
ments. 

Whichever  finger  is  chosen,  that  one  should  be  used  in  all  but 
unusual  cases,  because  it  is  desirable  to  educate  one  finger  to  feel 
correctly.  It  is  the  exceptional  physician  who  can  become  ambi- 
dextrous. 

Having  decided  on  the  left  forefinger,  it  should  be  lubricated 
because  the  external  genitals  are  dry,  and  pushing  in  the  external 
parts  causes  the  patient  discomfort ;  it  is  the  skin  which  is  in  need 
of  lubrication  rather  than  the  vagina,  which  is  supplied  normally 
with  a  lubricating  medium,  therefore  anoint  the  external  labia  and 
these  in  turn  will  lubricate  the  finger.  The  best  lubricant  is  some- 
thing of  the  nature  of  lubrichondrin,  sold  under  the  name  of  "muco- 
lubricans''  or  "K-Y,"  prepared  from  cartilage  treated  with  heat, 
a  mildly  antiseptic  jelly  containing  eucalyptol  or  gaultheria,  or 
some  other  substance  to  give  it  a  pleasant  odor.  It  is  soluble  in 
water.  It  is  kept  in  a  sterile,  collapsible  tube  and  is  free  from  all 
danger  of  contamination.  The  oils  and  vaseline  are  peculiarly  ill 
suited  for  lubrication  because  they  cling  to  the  finger  and  instru- 
ments and  are  well  adapted  to  receive,  retain,  and  distribute  patho- 
genic organisms.  Soaps  are  irritating  to  many  patients,  particu- 
larly in  inflammatory  conditions  of  the  external  genitals.  The 
physician  squeezes  from  the  tube  an  ample  quantity  of  lubri- 
chondrin on  to  the  dorsal  aspect  of  his  forefinger,  anointing  only  the 
terminal  and  second  phalanges.  By  bringing  the  hand  downward 
until  the  little  and  ring  fingers  touch  the  table  just  under  the  cleft 
of  the  buttocks,  the  tip  of  the  anointed  forefinger  seeks  the  perineum. 
When  it  is  reached  the  back  of  the  bent  forefinger  is  drawn  upward 
over  the  fourchette,  thus  lubricating  the  labia  and  the  vestibule, 
the  knuckle  falling  into  the  depression  at  the  introitus  vagina?. 
A  second  sweep  with  the  finger,  it  is  straightened,  and  the  tip  settles 
into  the  vagina.  It  is  to  be  noted  that  the  lubricant  has  been  put 
only  where  it  is  needed  and  that  there  is  none  on  the  unused  hand 
and  on  the  patient's  linen. 

In  introducing  the  finger  into  the  vagina  one  bears  in  mind  the 
condition  of  the  hymen  as  noted  at  the  previous  inspection.  If 
the  hymen  is  tight  great  gentleness  should  be  used  and  sufficient 


36  PHYSICAL  EXAMINATION 

time  allowed  for  dilatation.  Room  in  the  vagina  is  always  to  be 
gained  by  pressing  backward  toward  the  sacrum,  as  the  perineum 
and  pelvic  floor  are  dilatable  in  this  direction  only.  The  structures 
which  hug  the  under  surface  of  the  pubic  arch,  the  clitoris,  vestibule, 
anterior  vaginal  wall,  and  urethra  should  be  avoided  as  far  as 
possible,  as  in  that  region  sensation  is  most  acute. 

The  examining  finger  may  be  likened  to  a  small  speculum  as  it 
carries  down  the  perineum  and  opens  the  vagina.  In  many  cases 
it  is  possible  to  use  the  finger  in  the  place  of  a  speculum. 

As  soon  as  the  middle  knuckle  of  the  examining  finger  has  passed 
the  hymen  the  hand  is  turned  so  that  the  thumb  is  upward.  The 
three  unused  fingers  are  carried  behind  the  anus  in  the  cleft  of  the 
nates  and  the  thumb  is  moved  to  the  left  or  right  of  the  median 
line  out  of  the  way  of  the  clitoris.  The  perineum  and  pelvic  floor 
can  be  pushed  in  to  a  variable  extent  by  the  web  between  the 
index  and  middle  fingers  and  thus  the  examining  finger  reaches 
farther.  It  is  seldom  necessary  to  employ  two  fingers  for  the 
vaginal  examination,  although  there  are  cases  where  more  may  be 
learned  with  two  than  with  one.  The  palmar  surface  of  the  last 
phalanx  of  the  forefinger  is  the  chief  seat  of  the  trained  tactile 
sense.  As  a  rule,  particularly  in  virgins,  two  fingers  cause  the 
patient  a  great  deal  of  discomfort  and  therefore  accentuate  the 
disagreeable  features  of  the  examination,  tending  to  distress  of 
mind  and  body  and  consequently  preventing  the  relaxation  so 
essential  for  a  successful  investigation  of  the  contents  of  the  pelvis. 
The  scope  of  the  vaginal  touch  depends,  in  a  measure,  on  the  ana- 
tomical peculiarities  of  the  examiner's  hand.  A  physician  having 
thick,  chunky  hands  with  short  fat  fingers  can  not  hope  to  be  as 
good  a  gynecological  diagnostician  as  one  having  a  slim  hand  with 
long,  tapering  fingers.  In  women  of  spare  build  who  have  borne 
children,  practically  the  entire  inner  surface  of  the  pelvic  cavity 
may  be  palpated  by  a  long  finger  or  fingers  introduced  into  the 
vagina.  It  is  not  unusual  to  touch  the  promontory  of  the  sacrum 
and  the  sacro-iliac  synchondroses,  besides  all  parts  of  the  pelvic 
floor,  not  to  mention  the  structure's  occupying  the  pelvis.  (See 
Fig.  4.) 

The  examining  finger  as  it  enters  the  vagina  notes  the  following 
points: — rl  he  state  of  the  hymen,  whether  with  large  opening  or 
small,  whether  rigid  or  easily  dilatable:  the  vaginal  walls,  whether 


PALPATION 


37 


with  rugic  or  smooth,  whether  of  normal  temperature,  or  hot,  as 
in  the  case  of  inflammatory  affections  of  the  pelvic  organs,  or  in 
fevers;  whether  the  walls  of  the  vagina  are  in  apposition,  or  lax 
or  separated;  the  amount  of  secretion,  a  dry  vagina  giving  an  en- 
tirely different  sensation  from  a  moist  one;  the  condition  of  the 
pelvic  floor  and  perineum;  in  the  case  of  a  parous  woman  search 
for  a  groove  in  either  sulcus  or  the  middle  line,  remembering  the 
normal  conformation  of  the  perineum,  that  is  to  say,  a  convex 
surface  in  the  vagina  as  well  as  on  the  skin  outside;  sometimes  it' 
is  well  to  introduce  the  well-anointed  forefinger  of  the  right  hand 
in  the  anus  and  palpate  the  tissue  lying  between  the  two 


FIG.  4. — Half   a   Female   Pelvis,  with   Hand    in   Position    as   for   Vaginal 

Examination. 

fingers  in  order  to  get  a  correct  idea  as  to  injuries  which  may 
be  present.  The  vaginal  touch  informs  us  as  to  the  contents  of 
the  rectum,  whether  empty  or  containing  hard  fecal  masses,  semi- 
solid  feces,  or  dilated  by  fluid  or  gas;  also  whether  or  no  the  blad- 
der is  distended. 

In  order  to  practice  this  sort  of  palpation  successfully  re- 
quires a  long  experience  and  a  thorough  familiarity  with  the 
normal  conditions,  also  the  variations  of  the  normal  in  different 
individuals. 

Abnormalities  of  the  vagina  are  to  be  detected  by  touch;  such 
arc  cysts,  partial  septum,  narrowing  of  the  lumen  by  cicatrices, 


3S  PHYSICAL  EXAMINATION* 

the  sequela1  of  old  inflammatory  action,  or  from  congenital  defects 
of  development;   also  roughness,  as  in  granular  vaginitis. 

On  palpating  the  anterior  wall  of  the  vagina  the  urethra  is  felt, 
and  thickening  or  sensitiveness  of  this  structure— evidences  of 
inflammation — are  detected.  So  also  the  base  of  the  bladder  is  to 
be  touched  to  determine  thickening  or  points  of  tenderness,  in- 


FIG.  5. — Diagrammatic  Drawin 


the  Bimanual  Touch. 


dicating  the  situation  of  ulcerated  areas  in  the  bladder  niucosa. 
The  ureters  when  thickened  are  easily  palpable  running  from  the 
bladder  base  toward  the  sacro-iliac  synchondroses.  The  upper 
course  of  the  pelvic  portion  of  the  ureters  can  be  best  detected  by 
rectal  examination. 

(b)  The   Combined    Bimanual    Vaginal   and    Abdominal    Touch. — 
\\  hen    the    tip    of    the    examining    ringer    reaches    the    posterior 


PALPATION  39 

fornix  of  the  vagina  the  physician's  right  hand  is  laid  gently 
on  the  lower  abdomen,  palm  down  with  the  heel  of  the  hand 
just  above  the  symphysis  pubis.  Very  gentle  and  slowly  applied 
pressure  is  made  with  this  abdominal  hand,  all  sudden  movement 
being  avoided  as  calculated  to  excite  pain  and  consequently 
resistance  of  the  abdominal  muscles.  The  balls  and  not  the  tips 
of  the  fingers  are  used.  The  pelvic  organs  are  carried  down  by 
the  pressure  above  until  they  are  within  reach  of  the  finger  hi 
the  vagina,  and  conversely  they  are  raised  by  the  finger  below 
until  within  touch  from  above.  In  the  case  of  the  bimanual 
vagino-abdominal  touch  we  hold  between  our  hands  (the  finger  in 
the  vagina  and  the  hand  on  the  abdomen)  the  contents  of  a  box, 
the  cavity  of  the  pelvis. 

It  is  sometimes  a  help  in  making  the  bimanual  examination  for 
the  physician  to  rest  the  elbow  of  the  hand  making  the  vaginal 
touch  on  the  knee  of  the  corresponding  leg,  his  foot  being  placed 
on  the  chair  which  is  close  to  the  table. 

Factors  outside  of  the  condition  of  the  bowels  and  rectum 
limiting  what  can  be  felt  by  the  bimanual  touch  are,  the  amount  of 
adipose  tissue  present,  and  the  rigidity  or  laxity  of  the  muscles 
of  the  abdominal  walls.  A  rigid  perineum  has  been  referred  to 
already  as  lessening  the  amount  of  invagination  of  the  pelvic  floor 
that  ma}'  be  made  by  the  web  between  the  fingers  of  the  hand  at 
the  vulva. 

In  fat  women  both  the  vaginal  and  bimanual  touch  are  in- 
terfered with.  Other  things  being  equal,  it  is  impossible  to 
make  as  accurate  a  diagnosis  in  a  fat  woman  as  in  a  thin  woman. 
The  fat  in  the  perincal  region  reduces  the  scope  of  the  vaginal 
touch.  A  greater  hindrance  is  the  fat  in  the  abdominal  walls; 
with  two  or  three  inches  of  fat  in  the  panniculus  adiposus  the 
tactile  sense  is  much  blunted.  It  is  like  feeling  through  six  or 
eight  thicknesses  of  blankets.  Naturally,  then,  we  do  not  hope 
to  make  as  good  a  diagnosis  as  when  the  abdominal  walls  con- 
tain little  fat. 

A  rigid  abdomen  is  a  bar  to  diagnosis  by  touch.  One  can  feel 
very  little  through  a  stiff  sheet  of  pasteboard.  If  there  is  present 
peritonitis  or  great  sensitiveness  of  the  abdomen  from  any  cause 
wo  expect  to  find  rigidity.  Many  patients  become  rigid  through 
anxiety  and  fear  of  painful  manipulations  by  the  physician,  others 


40  PHYSICAL  EXAMINATION 

reflexly  because  of  the  discomfort  caused  by  the  laying  on  of  the 
hands.  Therefore1,  not  only  is  the  utmost  gentleness  imperative, 
but  also  it  is  a  matter  of  supreme  importance  not  to  arouse  the 
patient's  fears  by  brusk  behavior,  or  by  the  uncalled-for  display 
of  instruments. 

As  to  gentleness,  the  flat  hand  on  the  lower  abdomen  makes 
light  pressure  and  the  physician  inquires  whether  it  causes 
pain.  Distracting  the  patient's  attention  by  a  question  or  two 
often  prevents  rigidity.  Next,  the  hand  is  arched  by  flexing 
slightly  all  the  fingers  so  that  the  balls  of  the  fingers  press  in 
deeply.  It  is  very  essential  not  to  make  the  tips  of  the  fingers 
press,  the  same  rule  holding  here  as  in  massage.  Make  pressure 
with  the  palmar  surface  of  the  last  phalanges,  for  the  tips  of 
the  fingers  and  the  finger  nails  cause  pain,  and,  also,  less  can  be 
felt  with  the  tips. 

Ask  the  patient  to  take  a  long  breath;  as  she  does  so,  gently  hold 
the  abdominal  wall  in.  Repeat  the  process  and  the  examiner's 
hands  are  brought  nearer  and  nearer  together  with  each  expiration. 
Judgment  is  necessary  in  performing  this  maneuver  because  too 
rapid  or  too  forcible  pressure  will  cause  the  abdominal  muscles  to 
contract,  thus  defeating  the  objects  of  the  examination.  Assist- 
ance is  gained  in  some  rare  cases  by  drawing  down  the  cervix 
with  a  tenaculum  held  by  an  assistant.  In  this  way  the  back  of 
the  uterus  and  the  broad  ligaments  are  reached  and  also  tumors 
and  other  attachments  are  made  out. 

The  bimanual  or  conjoined  examination  is  the  keystone  of  the 
gynecological  diagnostic  arch.  Nothing  takes  the  place  of  the 
trained  touch,  and  it  is  doubtful  whether,  in  the  march  of  progress, 
any  form  of  investigation  will  supplant  it. 

Specula  for  the  vagina,  the  bladder,  and  the  rectum,  bacteriology, 
and  the  microscope  with  its  findings  as  to  the  nature  of  the  blood 
and  tissues,  and  the  .r-rays,  detecting  a  stone  in  the  bladder, 
ureter,  or  kidney,  all  have  their  uses.  The  bimanual  touch  is  the 
most  important. 

The  finger  in  the  vagina  notes,  first,  the  situation,  size,  conforma- 
tion, consistency,  and  sensitiveness  of  the  cervix;  lacerations, 
their  location  and  extent;  whether  or  no  the  tissues  of  the  cervix 
are  of  normal  consistency,  or  soft  as  in  septic  conditions  or  after 
labor,  or  indurated  as  in  chronic  metritis.  The  friable,  bleeding 


PALPATION  41 

cervix  of  cancer  is  rarely  mistaken  for  any  other  condition,  except 
possibly  a  sloughing,  pedunculated  fibroid. 

Cysts  of  the  Nabothian  follicles  can  be  diagnosticated  as 
shot-like  bodies;  a  stringy,  tenacious  plug  of  mucus  in  the  os 
can  be  differentiated  from  a  thin  discharge;  in  rare  cases  the 
cervix  may  be  out  of  reach,  being  forced  upward  into  the  abdomen 
by  a  tumor  in  the  pelvis  so  that  it  may  lie  on  a  level  with  the 
upper  border  of  the  symphysis  pubis;  the  different  situations  of 
the  cervix  in  the  various  malpositions  and  malformations  of  the 
uterus  will  be  considered  in  the  chapter  devoted  to  these  diseases. 
The  long  conical  cervix  found  especially  in  pathological  ante- 
flexion,  so  called,  is  readily  distinguished  from  its  opposites,  the 
apparently  short  cervix — one  in  which  the  vagina  has  been 
stripped  by  childbearing  from  its  attachments  to  the  portio,  or 
from  the  really  short  senile  cervix. 

The  pinhole  os  is  differentiated  by  touch  from  the  os  tincse. 
By  the  vaginal  touch  we  detect  a  polypus  projecting  from  the  os 
uteri.  In  the  case  of  large  polypi  we  detect  the  location  and  size 
of  the  pedicle  by  sweeping  the  finger  about  the  tumor  and  noting 
where  and  how  it  is  attached.  Sensitiveness  of  the  cervix  to  light 
pressure  indicating  endocervicitis  is  to  be  sought  for.  A  prolapsed 
ovary  or  tube  may  be  felt  on  one  side  of  the  cervix  and  an  excursion 
to  one  of  the  sacro-iliac  joints  may,  in  rare  cases,  detect  tenderness 
and  induration  there. 

Palpating  the  normal  ovary  by  the  bimanual  touch  is  a  difficult 
matter  unless  all  the  conditions  are  favorable.  These  are,  a  patient 
with  thin  and  relaxed  abdominal  walls  and  an  injured  perineum. 
Under  such  circumstances  the  ovary  may  be  rolled  between  the 
fingers  of  the  examiner's  hands.  Whenever  the  ovary  is  enlarged 
from  any  cause  its  palpation  is  rendered  easier.  In  -the  case  of 
rigid  abdominal  walls,  large  deposits  of  fat  in  these  structures,  a 
tight  hymen  and  unyielding  perineum,  the  palpation  of  the  ovary 
becomes  difficult.  Often  only  the  under  surface  can  be  felt,  and 
sometimes  only  by  a  rectal  examination.  Note  the  sensitiveness 
to  pressure  of  the  normal  ovary  and  in  the  case  of  a  diseased  ovary 
inquire  of  the  patient  if  the  pain  caused  by  pressure  is  the  same  as 
that  suffered  at  other  times. 

The  Fallopian  tube  can  not  be  felt  by  bimanual  examination 
unless  it  is  thickened  or  enlarged  by  disease.  In  this  event  it 


42  PHYSICAL  EXAMINATION 

may  bo  mapped  out   with  varying  degrees  of  exactness  according 
to  the  condition  of  abdominal  wall  and  perineum. 

An  abscess  in  the  pelvis,  whether  originating  in  the  tube,  the 
ovary,  the  vermiform  appendix,  the  sacro-iliac  joint,  or  coming 
from  above  in  the  psoas  muscle,  may  be  mapped  out  by  the  bi- 
manual  touch  and  a  point  of  fluctuation  found  if  it  exists. 


CHAPTER  V 

THE  PHYSICAL  EXAMINATION  (Continued) 

III.  The  examination  (continued) — 3.  Palpation  (continued) :  Anatomy 
of  the  pelvic  contents,  p.  43.  Barriers  to  infection,  p.  43.  Mobility  of  the 
uterus,  p.  44.  The  uterine  ligaments,  p.  44.  Mechanics  of  the  pelvic  and 
abdominal  contents,  p.  44.  The  pelvic  circulation,  p.  46.  The  normal 
position  of  the  uterus,  p.  49.  Structures  to  be  distinguished  by  palpation, 
p.  49.  Inferences  to  be  drawn  from  palpation,  p.  50.  (c)  The  rectal  touch, 
p.  50.  (d)  The  recto-abdominal  touch,  p.  53.  (e)  Gynecological  positions 
other  than  the  dorsal  position,  p.  53:  The  Sims  position,  p.  54;  The  knee- 
chest  position,  p.  56;  The  lithotomy  position,  p.  57;  The  raised  pelvis 
position,  p.  58;  The  standing  position,  p.  59. 

4.  Odor  as  a  diagnostic  sign,  p.  60. 

5.  The  collection  of  the  discharges  and  tissues  for  microscopic  examina- 
tion,   p.    61  :     Bartholin's    glands,    p.   61.      Skene's    glands,   p.   61.      The 
cervical  canal,  p.  62.     The  preservation  of  tissue,  p.  63. 


III.    THE  EXAMINATION  (Continued) 
3.  PALPATION  (Continued) 

BEFORE  describing  further  the  pathological  conditions  which 
may  be  diagnosed  b)^  the  bimanual  touch,  it  will  be  well  to  review 
some  points  in  the  anatomy,  physiology,  and  mechanics  of  the  pelvic 
organs.  No  attempt  will  be  made  to  give  a  complete  description 
such  as  may  be  found  in  text-books  of  anatomy. 

Think  of  the  pelvis  as  a  box,  closed  below  by  a  flexible  diaphragm, 
the  pelvic  floor,  and  open  above  into  the  abdominal  cavity.  Direct 
communication  between  the  pelvic  cavity  and  the  outside  world 
is  established  through  the  lumen  of  the  Fallopian  tubes,  the  uterine 
cavity,  and  the  vagina,  The  barriers  to  the  entrance  of  infective 
bacteria  to  the  peritoneum  are  (1)  the  narrowings  of  the  canals 
at  the  isthmus  of  the  tube,  the  internal  os  of  the  uterus,  and  the 
hymen,  and  (2)  the  downward  current  of  the  secretions,  partially 
maintained  by  the  cilia  of  the  lining  epithelial  cells,  partly  by 
peristalsis  of  the  tube,  and  also  by  coughing  and  straining. 

43 


44 


PHYSICAL  EXAMINATION 


The  uterus  occupying  the  center  of  the  pelvic  cavity  is  suspended 
with  its  long  axis  coinciding  with  the  long  axis  of  the  pelvis  and  at 
right  angles  to  the  long  axis  of  the  vagina.  An  important  point 
to  remember  is  that  it  is  suspended  and  oscillates  every  time  its 
owner  coughs,  sneezes,  laughs,  or  moves  about.  It  is  held  in  place 
by  certain  ligaments  to  which  it  is  attached,  by  its  connection  with 
the  vagina,  by  the  pelvic  floor  supporting  the  vagina,  and  by  the 
pressure  of  the  abdominal  contents. 

The  ligaments  are  folds  of  peritoneum  containing  connective 
tissue,  vessels,  and  nerves,  and,  in  the  case  of  the  round  and  utero- 


FK;.  f>. — Vertical  Median  Section  of  Body.     (Kelly.) 

sacral  ligaments,  a  few  muscle  fibers.  The  broad  ligaments  are 
on  both  sides  with  long  attachments  to  the  sides  of  the  uterus, 
thick  at  their  lower  portions,  reaching  from  the  cervix  nearly  to  the 
fundus  and  attached  at  their  other  ends  to  the  sides  of  the  pelvis. 
At  the  back  are  the  utero-sacral  ligaments,  attached  to  the  posterior 
surface  of  the  uterus  at  the  region  of  the  internal  os  and  extending 
to  the  back  wall  of  the  pelvis  at  the  level  of  the  second  or  third 
piece  of  the  sacrum.  The  utero-vesical  connective  tissue  is  in  front 
and  also  the  round  ligaments,  which  begin  as  large  fleshy  cords 


PALPATION 


45 


just  in  front  of  each  horn  of  the  uterus  and  extend  to  the  internal 
abdominal  rings,  becoming  smaller  and  smaller  as  they  approach 
their  insertion  in  the  fat  of  the  pubes. 

It  is  to  be  noted  that  when  a  woman  is  in  the  erect  position  (see 
Fig.  6)  the  insertions  and  origins  of  the  round  ligaments  lie 
practically  in  the  same  horizontal  plane,  therefore  these  ligaments 
act  rather  as  steadying  guys  than  as  supports  to  the  uterus.  In 
the  case  of  the  broad  ligaments  they  are  thick  and  strong  in  their 
lower  portions  and  really  support  the  cervix.  So  also  the  utero- 
sacral  ligaments  support  the  lower  uterine  segment  and  through 
it  the  upper  vagina.  The  attachments  of  the  vagina  to  the  cervix 
serve  to  steady  this  portion  of  the  organ  and  keep  it  in  its  proper 
relation  to  the  pelvic  floor.  The  supporting 
action  of  the  pelvic  floor  will  be  found  de- 
scribed in  more  detail  in  the  section  on  pro- 
lapse, Chapter  XIV,  page  220. 

The  abdominal  cavity  may  be  likened  to 
an  upright  cylindrical  vessel  filled  with  water 
and  closed  at  both  ends  by  an  elastic  mem- 
brane. The  weight  of  the  water  causes  the 
bottom  membrane  to  bulge  outward  and  the 
pressure  of  the  atmosphere  the  top  membrane 
to  sink  inward. 

In  the  case  of  a  living  woman,  standing 
erect,  the  diaphragm  represents  the  top  mem- 
brane, the  pelvic  floor  the  bottom  membrane. 

FIG.  7.— A  Vertical 

the  walls  of  the  abdomen  the  vessel,  and  the  Cylinder  closed  at  either 
liver,  stomach,  spleen,  kidneys,  pancreas,  in-  End  by  an  Elastic  Dia- 
testines,  and  uterine  organs  the  fluid.  The  P^dgm  and  Filled  with 
posterior  wall  of  the  abdomen  is  practically 

immovable  like  the  walls  of  the  tube,  but  the  anterior  wall  is  elastic 
and  capable  of  varying  within  wide  limits,  not  only  the  capacity  of 
the  abdominal  cavity,  but  the  pressure  exerted  on  its  contents. 

The  contents  of  the  abdominal  cavity  are  solid,  fluid,  and  gaseous, 
and  the  different  structures  are  stowed  so  closely  together  that 
there  is  no  waste  space  between  them.  The  pressure  which  can 
be  exerted  on  a  solid  organ  in  the  abdominal  cavity  such  as  the 
liver,  has  no  effect  other  than  to  compress  it  slightly  or  cause  it  to 
move  within  the  limits  permitted  by  its  suspending  ligaments. 


46  PHYSICAL   EXAMINATION 

According  to  a  law  of  physics,  pressure  on  tlie  fluid  contents  of  a 
closed  vessel  is  transmitted  with  equal  intensity  in  all  directions. 
Pressure  on  the  gaseous  contents  has  no  other  effect  than  slightly  to 
lessen  their  volume.  The  abdominal  organs  are  supported  by  their 
ligaments  and  mesenteries,  by  each  other,  by  the  abdominal  walls, 
—the  upper  ones  by  the  ribs, — by  the  anterior  projecting  lumbar 
spine,  and  by  the  shelf  of  the  false  pelvis  covered  by  the  psoas 
muscles.  (See  Fig.  86,  page  221.)  Therefore,  when  the  woman  is 
in  the  erect  posture  the  weight  of  the  abdominal  contents,  minus 
what  is  assumed  by  the  mesenteries  and  the  abdominal  walls,  rests 
on  the  anterior  face  of  the  lumbar  spine  and  the  slanting  brim  of 
the  false  pelvis,  on  the  lower  anterior  abdominal  wall,  and  also  on 
the  posterior  surface  of  the  uterus  and  the  broad  ligaments  and 
through  them  on  the  pelvic  floor.  Increased  pressure  due  to  con- 
traction of  the  abdominal  walls,  straining;  or  downward  excursion 
of  the  diaphragm,  coughing  and  sneezing;  is  transmitted  to  the 
fluid  contents  in  all  directions.  The  posterior  walls  of  the  abdomen 
are  rigid,  the  anterior  walls  are  rigid  when  contracted,  the  bony 
wall  of  the  pelvis  is  rigid,  the  pelvic  floor  is  elastic,  therefore  it 
bulges  downward,  like  the  membrane  on  the  bottom  of  the  vessel 
in  the  figure. 

If  instead  of  being  in  the  erect  posture  the  woman  is  in  the 
knee-chest  position,  the  conditions  are  reversed.  Now  the  weight 
of  the  abdominal  contents  comes  on  the  diaphragm  and  the  upper 
front  walls  of  the  abdomen,  the  pelvic  floor  is  depressed  inward 
like  the  upper  membrane  covering  the  vessel ;  when  the  vagina,  rec- 
tum, or  bladder  is  opened,  air  rushes  in  to  replace  the  negative 
pressure,  thus  maintaining  the  equilibrium  of  the  atmosphere, 
fifteen  pounds'  pressure  to  the  square  inch  exerted  in  all  directions. 

In  this  connection  the  pelvic  circulation  is  to  be  considered. 
Emmet  pointed  out  long  ago  (Trans.  Amer.  Gyn.  Soc.,  1887,  Vol. 
XII.,  p.  6~>)  that  the  veins  of  the  pelvis  are  without  valves,  and 
to  overcome  the  effect  of  gravity  their  course  is  extremely  tortuous. 
"Moreover,  this  provision  is  necessary  that  undue  traction  be 
not  made  upon  the  vessels  with  the  change  of  position,  and  with 
the  increasing  bulk  of  the  uterus  depending  upon  gestation."  He 
noted  the  fact  that  if  we  draw  down  a  healthy  uterus  to  a  certain 
point  near  the  floor  of  the  pelvis  and  hold  it  there,  the  cervix  and 
vaginal  mucosa  become  congested  very  soon,  as  evidenced  by  the 


f 

M 


47 


48  PHYSICAL  EXAMINATION 

dark  color  of  the  tissues,  denoting  venous  congestion  due  to  straight- 
ening out  of  the  tortuous  arteries  and  veins. 

If  the  traction  is  continued  until  a  portion  of  the  uterus  projects 
from  the  vagina,  the  tissues  become  blanched.  This  is  thought 
to  be  due  to  a  stretching  out  and  a  lessening  of  the  caliber  of  the 
arteries  so  that  the  blood  supply  is  cut  off.  The  connective  tissue 


FIG.  9.— The  Contents  of  the  Pelvis  from  Above.      (Kelly.) 

of  the  pelvis  is  as  the  trellis  to  the  grape-vine,  the  pelvic  fascia 
serving  as  a  firm  support  for  the  whole. 

On  each  side  of  the  uterus  are  the  ovaries  floating,  as  it  were, 
on  the  posterior  surface  of  the  broad  ligaments,  and  the  Fallopian 
tubes  extending  from  both  sides  of  the  fundus  uteri  to  the  outer 
extremities  of  the  ovaries.  The  ovaries  and  the  fimbriated  ends 
of  the  tubes  are  steadied  at  their  outer  ends  by  the  infundibulo- 
pelvie  ligaments,  otherwise  their  movements  are  regulated  by  the 


PALPATION  49 

movements  of  the  uterus,  broad  ligaments,  and  the  abdominal 
contents. 

The  bladder,  when  filled,  pushes  the  uterus  and  the  ovaries  and 
the  tubes  backward,  tending  to  cause  retroversion.  The  rectum, 
occupying  the  left  posterior  portion  of  the  pelvis,  when  distended 
tends  to  raise  the  uterus  and  also  makes  for  retroversion,  because 
limiting  the  backward  excursion  of  the  cervix. 

It  is  plain,  then,  that  the  normal  position  of  the  uterus  varies 
somewhat  according  as  the  woman  is  standing  or  is  lying  down, 
it  being  somewhat  more  anteverted  in  the  former  and  less  ante- 
verted  in  the  latter,  because  of  the  effect  of  gravity  and  the  vary- 
ing pressure  of  the  abdominal  contents  on  the  fundus.  Also  its 
position  as  well  as  its  mobility  varies  according  to  the  state  of 
fullness  of  the  bladder  and  the  rectum. 

In  practicing  bimanual  palpation  the  following  structures  are  to 
be  felt:  the  symphysis  pubis;  the  promontory  of  the  sacrum;  the 
uterus;  the  ovaries;  the  Fallopian  tubes,  when  diseased  so  that  they 
are  thickened  or  enlarged ;  the  appendix  vermiformis,  very  excep- 
tionally and  only  when  thickened  or  enlarged  by  disease;  the  rectum 
and  bladder,  only,  as  a  rule,  when  their  walls  are  thickened. 

In  rare  cases  having  lax  and  thin  abdominal  parietes  a  thick- 
ened ureter  may  be  palpated  at  the  point  where  it  crosses  the 
pelvic  brim  just  outside  the  internal  iliac  artery  and  the  sacro- 
iliac  joint.  A  thickened  ureter  may  be  felt  always  for  two  inches 
or  so  after  it  leaves  the  bladder.  In  favorable  cases  the  normal 
ureters  may  be  palpated  per  vaginam,  but  this  is  a  fine  point  and 
not  an  accomplishment  of  many  physicians. 

On  making  downward  pressure  on  the  abdomen  the  promontory 
of  the  sacrum  is  felt  just  below  the  level  of  the  umbilicus.  Midway 
between  the  promontory  and  the  symphysis  pubis,  or  a  trifle  nearer 
the  symphysis,  the  fundus  uteri,  if  normally  placed,  is  to  be  made 
out.  In  the  erect  posture  the  external  os  uteri  is  on  a  level  with 
the  upper  margin  of  the  symphysis  pubis;  in  the  recumbent  at- 
titude the  os  is  slightly  higher. 

Steadying  the  cervix  with  the  vaginal  finger  the  examiner  moves 
the  uterus  up  and  down  and  from  side  to  side,  thus  gaining  an 
idea  of  the  mobility,  whether  normal  or  limited  by  past  or  present 
inflammatory  action  in  the  surrounding  tissues,  or  by  a  tumor  or 
a  full  bladder. 


50 


PHYSICAL  EXAMINATION 


The  uterus  may  bo  displaced  as  a  whole  downward  in  the  axis 
of  the  pelvis  (prolapse),  or  backward  (retroposition),  or  excep- 
tionally upward.  Alterations  in  the  axis  constitute  retroversion 
(often  made  to  include  retroposition)  and  anteversion.  Lateral 
versions  are  of  little  importance. 

Besides  the  situation,  axis,  and  mobility  of  the  uterus,  one  notes 
its  form  (abnormalities,  flexions,  and  tumors),  its  size  (atrophic 
or  hypertrophic),  and  its  density  (soft  in  pregnancy  and  septic 
conditions  and  hard  in  chronic  inflammation  and  in  many  tumors). 


FIG.  9o. — Normal  Female  Pelvis. 


Pressure  on  the  uterine  body  eliciting  tenderness  denotes  en- 
dometritis;  and  tenderness  of  the  cervix,  endocervicitis. 

Tumors  anywhere  in  the  pelvis  are  to  be  placed  accurately,  and 
their  size,  form,  consistency,  and  sensitiveness  to  pressure  de- 
termined, also  their  relation  to  the  pelvic  organs.  This  relation 
is  established  often  by  moving  the  tumor  and  noting  if  the  uterus 
moves,  or  vice  versa. 

In  acute  pelvic  inflammation  the  abdominal  walls  arc  apt  to  be 
rigid  because  of  the  peritonismus  which  is  generally  present.  Under 
these  conditions  little  can  be  learned  except  by  the  vaginal  touch. 

Exceptionally  it  is  best  to  combine  instruments  with  the  bi- 
rnanual  touch  as  described  in  Chapter  VII. 

((•}  The  Rectal  Touch. — This  method  of  examination  is  resorted 
to  in  order  to  gain  a  slightly  higher  reach  in  the  pelvis  and  also  in 


PALPATION  ;  r>&i\'  GF 

cases  where  it  is  inadvisable  to  make  the  vaginal  touch,  'as  iii 

i^i™^   ^  ^~-  \  f~  \r\\f     **•      ^~  /  f  r™1  f* 

young  girls,  a  virgin  with  a  rigid  hymen,  the  cas'e  Jof'a  narrow, 
shallow  vagina,  or  a  congenital  or  acquired  atresia  of  this  organ. 

In  making  a  rectal  examination  it  is  desirable  to  use  a  large 
amount  of  lubricant  because  of  the  tightness  of  the  anus.  The 
digital  examination  of  the  rectum  causes  much  more  discomfort 
to  most  women  than  the  digital  examination  of  the  vagina.  There- 
fore, every  reasonable  device  should  be  employed  to  lessen  the 
discomfort,  and  also,  unless  the  finger  is  well  lubricated,  the  anus 
will  grasp  it  so  tightly  as  to  interfere  with  its  tactile  sense.  It  is 
well  to  use  a  thin  rubber  cot  for  the  rectum,  removing  it  as  soon  as 
this  part  of  the  examination  is  over.  Before  making  the  examina- 
tion the  anal  region  is  smeared  freely  with  muco-lubricans  and  the 
left  forefinger  is  thoroughly  anointed  as  well. 

Sometimes  in  patients  who  are  annoyed  by  an  accumulation 
of  gas  in  the  rectum  it  is  well  to  let  this  gas  out  before  making  the 
examination,  by  passing  a  catheter  through  the  anus  before  in- 
troducing the  finger.  As  a  rule,  however,  the  presence  of  gas  in 
the  rectum  facilitates  the  examination.  The  vaginal  touch,  if 
it  has  preceded  the  rectal  touch,  will  give  an  inkling  as  to  the 
condition  of  the  rectum.  The  presence  of  fecal  matter  calls  for 
an  enema. 

In  passing  the  finger  through  the  anus,  note  the  tonicity  and 
strength  of  the  sphincter  ani.  In  the  case  of  hemorrhoids  or 
fissure,  where  there  has  been  long-standing  irritation  with  consequent 
increased  muscular  action,  the  sphincter  will  be  found  in  many 
cases  to  be  hypertrophied.  The  sphincter  may  be  weak  and 
insufficient  because  of  injury  received  during  childbirth  or  by  over- 
stretching at  the  hands  of  a  surgeon,  or  in  cases  of  rectal  prolapse 
or  atrophic  catarrh. 

A  fissure  by  presenting  a  localized  point  of  sensitiveness,  hem- 
orrhoids by  giving  a  feeling  of  lumps  in  the  rectal  wall,  and  also 
polypi  by  their  feeling  of  pedunc illation,  may  be  detected  by* 
touch.  The  situation  of  the  opening  of  a  fistula  in  ano  into  the 
bowel  can  not  be  determined  without  the  aid  of  a  probe.  Through 
the  thin  anterior  rectal  wall  the  examining  finger  makes  out  the 
cervix,  the  bases  of  the  broad  ligaments,  and  the  utero-sacral  liga- 
ments. By  raising  the  uterus,  these  ligaments  are  put  on  the 
stretch  and  an  idea  may  be  obtained  as  to  their  relative  length 


32  PHYSICAL   EXAMINATION 

and  thickness.  The  posterior  wall  of  the  uterus  is  very  accessible 
through  the  rectum. 

The  ovaries  and  tubes  if  prolapsed  may  be  palpated  advanta- 
geously by  the  rectal  touch. 

Through  the  posterior  wall  of  the  rectum  the  coccygeal  and 
sacral  vertebne  may  be  felt,  and  fractures  and  dislocations  of  the 
coccyx  determined.  Pain  caused  by  pressure  on  the  coccyx  may 
mean  coccygodynia.  (See  Chapter  X.,  page  159.) 

Infiltrations  or  new  growths  in  the  recto-vaginal  septum  are 
to  be  mapped  out,  as  to  size,  situation,  consistency,  and  sensitive- 


FIG.   10. — Half  a  Female  Pelvis,  Showing  Accessibility  of  Contents  to  Palpation. 

ness,  by  combined  vaginal  and  rectal  touch,  the  finger  of  one  hand 
being  in  the  vagina,  and  the  forefinger  of  the  other  hand  in  the 
rectum.  The  presence  of  new  growths  and  strictures  in  the 
rectum  is  diagnosed  by  the  rectal  touch. 

Too  great  care  can  not  be  exercised  in  washing  the  hands  before 
changing  from  a  rectal  to  a  vaginal  examination  and  vice  versa, 
because  of  the  danger  of  transferring  infective  matter  from  one  organ 
to  the  other.  In  the  case  of  acute  infective  inflammation  of  the 
vulva  and  vagina,  it  is  wiser  not  to  examine  the  rectum  at  all. 
Often  the  rectal  examination  mav  be  deferred  as  well  to  a  later  date. 


PALPATION 


53 


By  the  rectum  it  is  possible  to  palpate  the  branches  of  the  sacral 
plexus  of  nerves  where  they  course  along  the  sides  of  the  pelvis, 
and  also  to  palpate  a  psoas  abscess  or  disease  of  the  sacro-iliac 
articulation. 

(d)  The  bimanual  recto-abdominal  touch  is  the  same  as  the 
bimanual  vagino-abdominal  touch  as  regards  the  structures  which 
are  reached,  except  that  greater  opportunity  is  generally  afforded 


FIG.    11. — The  Sims  Position. 

for  exploration  of  the  cul-de-sac  of  Douglas  and  its  contents,  than 
by  the  bimanual  vagino-abdominal  touch. 

Digital  exploration  of  the  bladder  is  an  unjustifiable  procedure,  as 
all  the  information  obtained  by  touch  may  be  gained  by  a  speculum 
examination  and  by  vaginal  and  rectal  touch.  The  danger  of 
incontinence  of  urine  is  too  great  to  justify  introducing  the  finger 
through  the  urethra,  no  matter  how  small  the  finger  may  be. 

(e)  Gynecological  Positions  other  than  the  Dorsal  Position. — 
Besides  the  dorsal  position  which  has  been  described  already,  there 
are  several  other  positions  into  which  the  patient  is  put  for  pur- 
poses of  examination. 


54 


PHYSICAL  EXAMINATION 


They  arc: — the  Sims,  tho  knee-chest,  the  lithotomy,  the  raised 
pelvis,  and  the  standing  positions. 

The  tiims  position  is  not  so  frequently  used  now  as  in  the  years 
following  the  invention  of  the  Sims  speculum.  Still,  it  is  of  great 
service  both  for  the  use  of  the  speculum  and  other  instruments, 
for  practicing  the  bimanual  touch,  and  for  examination  of  the  anus 
and  rectum.  For  some  reason  not  altogether  clear,  the  illustra- 
tions introduced  into  all  but  one  or  two  text-books  on  gynecology 
to  show  this  position,  do  not  figure  it  correctly  as  it  was  devised 

by  Sims  or  as  it  is  used  in 
the  hospital  where  he  did 
his  work,  the  Woman's 
Hospital  in  the  State  of 
New  York.  As  commonly 
shown,  the  patient  is  lying 
on  her  left  side  with  thighs 
only  partly  flexed  on  the 
abdomen,  in  the  middle  of 
a  long  table;  her  head  is 
generally  on  the  left  side 
of  the  table,  her  hips  in  the 
middle,  and  so  far  from  the 
bottom  edge  that  the  gen- 
itals are  entirely  inaccess- 
ible for  examination. 

Suppose  we  have  finished 
with  the  dorsal  position 
and  wish  to  put  our  patient 
in  the  Sims  position.  Pull- 
ing the  sheet  off  and  holding  it  in  front  of  her  we  give  her  a  hand 
and  ask  her  to  stand  in  the  chair  at  the  foot  of  the  table.  Then 
we  pull  out  the  little  slide  for  a  foot  rest  in  the  right-hand  lower 
corner  of  the  table  and  place  the  pillow  for  the  head  diagonally 
about  midway  along  the  right  edge  of  the  table.  Now  we  ask  her 
to  raise  her  skirts  and  to  sit  on  tho  left-hand  corner  of  the  table, 
sitting  as  far  over  to  the  left  as  she  can  and  turning  on  her  left 
side  and  drawing  up  her  knees  as  she  lies  down.  Throw  the  sheet- 
over  the  hips  as  soon  as  she  gets  down.  Next  ask  her  to  put  her 
left  arm  over  the  left  edge  of  the  table  and  help  her  to  do  it, 


FIG.   12. — Diagram  of  the  Sims  Position. 


PALPATION  55 

See  that  her  head  is  on  the  pillow  on  the  right  side  and  that  she 
is,  as  it  were,  doubled  up  like  a  jack-knife.  Then  the  physician 
stands  on  the  left  of  the  table  facing  the  patient's  hips,  pulls  them 
(asking  at  the  same  time  for  the  patient's  assistance)  to  the  left, 
until  the  back  of  the  sacrum  is  even  with  the  left  edge  of  the  table, 
and  the  lower  margin  of  the  buttocks  corresponds  with  the  lower 
edge  of  the  table.  The  feet  are  now  on  the  foot  rest,  or,  in 
default  of  this,  on  the  back  of  a  chair  padded  with  a  folded  blanket, 
or  on  a  table.  The  upper,  the  right  knee  is  advanced  a  little 
beyond  its  fellow,  and  the  inner  edge  of  the  sole  of  the  right  foot 
rests  on  the  instep  of  the  left  foot. 

A  fresh  towel  opened  out  is  made  to  cover  the  lower  buttock 
and  thigh  by  tucking  one  end  into  the  drawers  behind,  and  carry- 
ing the  other  end  between  the  thighs  in  front.  The  free  end  below 
is  tucked  under  the  covering  of  the  table.  The  upper  buttock 
and  thigh,  the  legs  and  feet,  and  the  rest  of  the  body  are  covered 
by  the  sheet, 

In  this  position  the  pelvis  is  inclined  at  a  slight  angle  to  the 
table,  the  abdominal  contents  fall  away  from  the  pelvis,  leaving 
the  pelvic  organs  free  from  pressure;  the  abdominal  walls  are 
relaxed  and  the  vagina,  ballooned  by  air  admitted  by  the  speculum, 
can  be  most  easily  inspected. 

It  is  difficult  to  put  very  stout  women,  or  patients  with  large 
abdominal  tumors,  in  this  position  and  in  these  cases  the  Sims 
position  is  of  less  value  than  in  thinner  subjects. 

The  important  points  are  to  get  the  patient's  back  on  a  level 
with  the  left  edge  of  the  table  and  the  head  on  the  right  edge  of 
the  table.  Unless  the  patient  is  put  in  the  correct  position  it  is  of 
no  value  whatever.  Unless  the  thighs  are  sharply  flexed  on  the 
abdomen  and  the  hips  are  at  the  edge  of  the  table,  the  physician 
can  neither  look  into  the  vagina  nor  make  manipulations  to  ad- 
vantage. 

The  bimanual  vagmo-abdominal  or  recto-abdominal  touch  is 
made  with  the  patient  in  the  Sims  position  by  introducing  the  left 
forefinger  in  either  vagina  or  rectum  and  the  right  hand  between 
the  thighs,  asking  the  patient  to  raise  her  right  thigh  until  the  hand 
is  in  place  and  then  letting  it  drop  again. 

The  Sims  position  is  useful  also  for  palpating  uterine  and  ova- 
rian tumors;  with  the  patient  in  this  position,  relaxation  of  the 


56  PHYSICAL  EXAMINATION 

abdominal  walls  may  ho  obtained  often,  when  it  can  not  be  with 
the  patient  in  the  dorsal  position. 

The  knee-chest  position,  or  knee-elbow  position,  as  it  is  some- 
times called,  is  another  gynecological  position  commonly  wrongly 
figured  in  the  text-books.  The  patient  stands  in  the  chair  at  the 
foot  of  the  examining  table  facing  the  table.  She  raises  her  skirts 
in  front  and  places  one  knee  near  one  corner  of  the  table,  the  other 


FIG.   13. — The  Knee-Chest  Position. 

knee  follows  and  takes  its  place  at  the  opposite  corner  of  the 
table.  Then  she  bends  forward  and  places  her  hands  in  the  middle 
of  the  table  while  the  physician  throws  the  sheet  over  her.  The 
feet  and  legs  are  left  projecting  over  the  table's  edge,  but  the 
position  is  not  uncomfortable,  for  all  the  weight  comes  on  the 
knees  and  hands.  Now  the  patient  is  on  her  hands  and  knees  on 
the  table.  The  physician  folds  a  good-sized  pillow  once  and 


PALPATION 


57 


places  it  in  the  middle  of  the  table.  The  patient  is  asked  to  place 
her  head  and  chest  on  the  pillow  with  her  face  to  one  side,  letting 
herself  down  on  to  her  elbows  as  she  does  so.  The  physician  next 
goes  to  the  foot  of  the  table,  throws  the  skirts  above  the  hips 
under  the  sheet  and  drapes  each  thigh  with  the  sides  of  the  sheet. 
Note  now  whether  the  thighs  are  vertical.  They  are  apt  not  to 
be,  as  the  patient  generally  throws  her  chest  too  far  forward,  thus 
slanting  the  thighs.  If  they  are  not  vertical  they  are  easily  made 
so  by  asking  the  patient  to  move  her  chest  back  a  little  as  the 
pillow  is  moved  for  her  in  the  same  direction. 
The  knee-chest  position  is  most  useful  for  speculum  examina- 


FIG.   14. — The  Knee-Chest   Position.     Side  View,  Showing  Vertical  Thighs. 

tions  of  the  vagina,  bladder,  and  rectum,  the  abdominal  pressure 
being  removed,  and  the  viscus  in  which  the  speculum  is  placed 
being  ballooned  by  the  atmospheric  pressure  admitted  by  opening 
the  external  orifice. 

To  replace  a  retro  verted  or  retroflexed  incarcerated  uterus, 
or  an  incarcerated  tumor  of  the  pelvis,  often  necessary  to  establish 
a  diagnosis,  the  knee-chest  position  is  invaluable. 

The  lithotomy  position  is  the  dorsal  position  with  the  thighs 
flexed  on  the  abdomen.  The  position  is  maintained  by  leg  holders, 
of  the  Von  Ott,  Robb,  or  the  Clover's  crutch  patterns,  by  different 
forms  of  slings  holding  the  flexed  thighs  to  the  shoulders  of  the 


58  PHYSICAL   EXAMINATION 

patient  with  straps,  or  by  leg  holders  attached  to  the  operating 
table.  The  patient  is  placed  in  the  lithotomy  position  just  as 
in  the  dorsal  position,  with  the  addition  that  the  thighs  are  kept 
flexed  by  some  device.  Without  any  apparatus  whatever  it  is 
possible,  and  often  convenient,  especially  in  short  operations, 
such  as  curetting,  for  one  assistant  to  hold  both  legs  with  one 
hand  and  have  the  other  hand  free  to  assist  the  physician.  To 
do  this,  the  assistant,  generally  a  nurse,  places  herself  on  the  left 
side  of  the  table  (the  patient's  right  side),  facing  the  physician,  who 


FIG.   15. — The  Lithotomy  Position. 

is  seated  in  the  chair  at  the  foot  of  the  table.  She  reaches  across  the 
patient's  flexed  limbs  with  her  left  arm,  letting  the  right  knee  rest 
in  her  left  axilla  and  grasping  the  left  leg  with  her  left  hand.  Thus 
her  right  hand  is  free  to  hold  instruments  for  the  doctor. 

The  lithotomy  position  is  used  for  examinations  under  ether, 
for  operations,  and  for  investigations  where  it  is  necessary  to 
scrub  up  and  asepticize  the  vulva  and  surrounding  regions. 

The  raised  pelris  position,  used  only  in  cystoscopic  examina- 
tions, is  an  exaggerated  lithotomy  position.  It  is  best  obtained 
on  a  table  which  has  a  mechanism  for  the  Trendelenburg  posture, 


PALPATION 


59 


but  may  be  secured  by  placing  a  hassock  or  hard  cushions  covered 
with  towels  under  the  sacrum,  so  that  the  pelvis  is  elevated  about 
ten  inches  above  the  level  of  the  table,  the  legs  being  held  by  a 
Robb  leg  holder  or  by  an  assistant  standing  on  a  stool  or  box. 
This  position  tilts  the  pelvis  backward  and  removes  abdominal 
pressure  from  the  bladder. 

The  standing  position  is  of  occasional  use  in  determining  the 
degree  of  prolapse  of  the  uterus  and  vaginal  walls  when  full  ab- 
dominal pressure  is  exerted,  also  the  axis  of  the  uterus  under  these 
conditions,  and  the  holding  power  of  a  pessary. 


The  Raised  Pelvis  Position. 


The  patient  stands  facing  the  physician  with  her  right  foot 
resting  on  a  round  of  a  chair  eight  or  ten  inches  from  the  floor. 
The  physician  kneels  on  his  left  knee  in  front  of  her,  or  sits  in  a 
low  chair  resting  his  left  elbow  on  his  left  knee.  He  anoints  his 
left  forefinger,  and  steadying  himself  with  his  right  hand  on  her 
left  hi}),  finds  the  vulva  by  sweeping  the  anointed  middle  finger 
of  his  left  hand  over  the  anal  region,  and  then  introduces  the  fore- 
finger, just  as  in  the  vaginal  examination  in  the  case  of  the  dorsal 
position.  Having  the  patient  bear  down  or  cough  gives  an  idea 
as  to  the  excursion  of  the  uterus  with  forced  expiration. 


00 


PHYSICAL  EXAMINATION 


4.   ODOR  AS  A  DIAGNOSTIC  SIGN 

The  sense  of  smell  is  sometimes  an  aid  to  diagnosis,  as  in  detect- 
ing the  characteristic  odor  of  the  vaginal  discharge  from  uterine 
cancer,  and  the  odor  of  urine  or  feces  in  the  vaginal  discharges  in 
the  case  of  urinary  or  fecal  fistula*.  Menstrual  blood  has  a  different 
odor  from  other  blood.  Certain  vaginal  discharges  have  a  pecul- 


FICJ.    17. — The  Standing  Position. 

iarly  foul  odor.  The  odor  exhaled  by  a  patient  suffering  with 
septicemia  is  characteristic,  although,  like  other  odors,  not  capable 
of  definite  description.  Diabetic  urine  has  a  sweet  smell  and 
urine  may  be  distinguished  from  other  discharges  by  administering 
spirits  of  turpentine  or  asparagus  to  the  patient  by  the  month  and 
noting  the  odor  of  violets  or  asparagin  in  the  urine. 


COLLECTION  OF  DISCHARGES  AND  TISSUES  61 

Acetonemia,  a  form  of  intoxication  with  acetone  occurring  in 
diabetes,  in  infectious  fevers,  in  intestinal  fermentation,  in  gen- 
eral sepsis,  and  sometimes  following  gynecological  operations, 
may  be  distinguished  by  the  sweetish  odor  of  the  breath, 
described  as  like  that  of  a  pippin  apple. 

5.  THE  COLLECTION  OF  THE  DISCHARGES  AND  TISSUES  FOR 
MICROSCOPIC  EXAMINATION 

Materials  Needed. — 1.  Half  a  dozen  absolutely  clean  cover 
glasses.  2.  A  few  culture  tubes  of  hydrocele  agar  or  blood  serum 
(furnished  by  the  pathologist).  3.  Platinum  wire  loop.  4.  Alcohol 
lamp.  5.  Long-handled  sharp  knife.  6.  Long-handled  sharp- 
pointed  scissors.  7.  Uterine  tenaculum.  8.  Uterine  dressing  for- 
ceps. 9.  Needle-holder,  curved  needle,  and  catgut.  10.  Gauze 
packing.  11.  Small  bottle  of  ten-per-cent  formalin. 

Bartholin's  Glands. — If  the  discharge  from  the  glands  of  Bar- 
tholin  is  to  be  collected  for  examination  for  gonococci  or  tubercle 
bacilli,  the  labia  are  separated  and  the  vulva  is  wiped  dry  with 
sterile  cotton  pledgets.  Grasp  the  gland  to  be  investigated  be- 
tween the  thumb  and  forefinger,  make  gentle  pressure,  and  transfer 
the  discharge,  which  exudes  from  the  mouth  of  the  gland's  duct,  to 
a  cover  glass  by  means  of  a  platinum  wire  loop  or  uterine  applicator 
which  has  been  passed  previously  through  the  flame  of  an  alcohol 
lamp.  Place  a  clean  cover  glass  upon  the  first  one,  press  the  two 
gently  together  to  spread  the  discharge  evenly,  slide  the  two  apart, 
and  allow  to  dry.  The  dry  cover  glasses  may  then  be  reapplied 
face  to  face  and  held  together  by  an  elastic  band.  They  are  then 
placed  in  an  envelope  which  is  labeled  as  follows: — 

Name  of  patient : 

Date: 

Source  of  material: 

Examine  for  (organism): 

Sent  by  Dr.- 

The  preparation  properly  labeled  is  then  sent  to  the  pathol- 
ogist for  examination. 

Skene's  Glands. — The  orifice  of  the  urethra  and  the  introitus 
vagina*  are  wiped  dry  with  sterile  cotton  pledgets.  Introduce  the 
finger  into  the  vagina  and  make  gentle  pressure  from  above  down- 


62  PHYSICAL  EXAMINATION 

ward  along  the  course  of  the  urethra.  As  the  ducts  of  Skene's 
glands  open  into  the  urethra  just  inside  the  urethral  labia,  any 
discharge  from  these  ducts  will  contain  a  certain  admixture  of 
urethral  discharge  also.  The  urethra  can  hardly  become  infected 
without  accompanying  infection  of  Skene's  glands,  but  this  mixture 
with  urethral  discharge  is  unimportant  from  a  clinical  standpoint. 
If  it  is  essential  to  examine  the  discharge  from  Skene's  glands  apart 
from  that  from  the  urethra,  then  the  latter  canal  must  be  walled 
off  with  a  small  cotton  pledget  and  pressure  made  only  over  Skene's 
gland.  Transfer  the  discharge  obtained  to  cover  glasses  as  de- 
scribed under  Bartholin's  glands. 

The  Cervical  Canal. — The  patient  is  placed  in  the  Sirns  position 
by  preference,  although  the  procedure  may  be  successfully  carried 
out  in  the  dorsal  position.  A  speculum  is  introduced  and  the 
vagina  cleansed  with  sterile  cotton  and  water  and  then  dried  with 
dry  cotton.  A  good  exposure  of  the  cervix  can  usually  be  obtained 
without  the  use  of  a  tenaculum.  The  use  of  a  tenaculum  is  often 
accompanied  by  bleeding  which  may  contaminate  the  cervical 
discharge.  Sometimes  it  is  necessary  to  draw  the  cervix  down 
with  a  tenaculum.  In  this  case  the  instrument  should  be  firmly 
fixed  at  the  first  attempt  and  held  in  place.  A  sterile  tampon 
screw  is  most  useful  in  obtaining  cervical  discharge.  The  instru- 
ment is  introduced  into  the  cervical  canal  not  beyond  the  internal 
os  and  twisted  until  some  of  the  discharge  has  been  caught  in  the 
threads  of  the  screw.  Whether  obtained  with  the  screw  or  with 
the  platinum  wire  loop  the  smear  is  made  as  described  in  the  case 
of  the  glands  of  Bartholin  and  Skene. 

Cultures. — If  cultures  for  the  purpose  of  obtaining  a  bacterial 
growth  from  a  discharge  are  to  be  made,  the  culture  tubes  are 
used.  Collect  a  drop  of  the  discharge  on  the  sterile  small  wire 
loop  which  comes  with  the  tube  and  smear  it  over  the  slanting 
surface  of  the  material  in  the  tube.  Replace  stopper,  label  care- 
fully, and  return  to  the  pathologist.  It  is  possible  to  introduce 
the  small  wire  loop  into  most  cervical  canals  without  dilatation,  and 
it  is  much  better  to  take1  the  culture  or  smear  without  dilating 
the  canal,  because  in  the  process  of  dilating  the  discharges  are 
partly  removed  and  mixed  with  blood  and  tissue. 

Removal  of  Tissue  from  the  Cervix  for  Examination. — The  Sims 
position  usually  offers  the  best  exposure  of  the  cervix  for  the 


COLLECTION  OF  DISCHARGES  AND  TISSUES  63 

removal  of  pieces  of  tissue  for  examination.  In  removing  a 
suspicious  piece  of  tissue  for  microscopic  examination  it  is  wise 
to  cut  out  some  of  the  apparently  healthy  tissue  as  well  as  the 
diseased  portion,  for  it  occasionally  happens  that  the  pathologist 
receives  nothing  but  necrotic  tissue  and  can  form  from  it  no  diag- 
nosis whatever.  A  raw  surface  left  by  removal  of  tissue  should  be 
closed  by  suture  or  tamponed  until  all  bleeding  has  been  checked. 
Tissues  removed  by  the  curette,  scissors,  or  knife  for  the  purpose 
of  diagnosis,  are  to  be  plunged  intact  and  immediately  into  a  ten- 
per-cent  solution  of  formalin  in  water;  then  they  are  properly 
labeled,  and  sent  to  the  pathologist. 


CHAPTER  VI 
THE  PHYSICAL  EXAMINATION  (Continued) 

III.  The  examination  (continued):  6.  Inspection  of  the  abdomen,  p.  64. 
Method  of  performing  it,  p.  65.  Appearances  to  be  noted,  p.  65.  En- 
teroptosis,  p.  67. 

7.  Palpation  of  the    abdomen,    p.  68.     Method   of   performing  it,  p.  69. 
Points  to  be  determined  by  palpation,  p.  69.     Palpation    of  the  kidneys,  p. 
70. 

8.  Percussion  of  the  abdomen,  p.  71  :     Auscultation  of  the  abdomen,  p. 
72  ;     Mensuration  of  the  abdomen,  p.  74  ;      Gauze   records  of  abdominal 
tumors,  p.  74;     The  X-rays  in  diagnosis,  p.  76. 

III.    THE  EXAMINATION    (Continued) 

6.  INSPECTION  OF  THE  ABDOMEN 

ATTENTION  will  be  directed  to  the  abdomen  to  a  greater  or  a 
less  degree  according  to  the  nature  of  the  disease  present  in  any 
given  instance.  In  the  case  of  late  pregnancy,  and  of  tumors  of 
abdominal  evolution,  whether  originating  in  the  pelvis  or  not, 
investigation  of  the  abdomen  is  of  chief  importance. 

In  suspected  uterine  disease  the  vaginal  and  bimanual  examina- 
tions usually  precede  the  examination  of  the  abdomen.  In  the 
case  of  a  large  abdominal  swelling  the  abdomen  is  first  inspected. 

For  the  examination  of  the  abdomen  it  is  not  so  necessary  that 
the  patient  should  lie  on  a  hard  surface  as  in  the  case  of  the  vaginal 
examination.  However,  the  table  is  most  convenient  for  the 
physician  because  he  can  stand  up  and  make  his  inspection,  palpa- 
tion, percussion,  and  mensuration  when  in  a  position  comfortable 
to  himself;  not,  as  in  the  case  where  the  patient  is  on  a  low  bed  or 
couch,  with  bent  back  and  strained  muscles,  conditions  which  are 
not  conducive  to  most  careful  investigation.  The  patient  on  a 
table  is  comfortable  enough  for  the  brief  time  required  for  the 
examination. 

All  the  patient's  clothing  has  been  loosened  and  the  corsets 

64 


INSPECTION  OF  THE  ABDOMEN 


65 


removed,  as  previously  described.  The  sheet  covers  the  legs, 
thighs,  and  pubic  region.  The  raised  skirts  cover  the  chest,  or, 
if  the  skirts  have  been  removed,  another  sheet  is  used  for  this  pur- 
pose. 

To  investigate  the  abdomen  to  the  best  advantage  the  patient's 
head  should  be  raised  a  little  on  a  pillow  and  the  thighs  should  be 
slightly  flexed.  Too  much  flexing  of  the  thighs  or  raising  the  head 
and  thorax  high  will  decrease  the  portion  of  the  abdomen  available 
for  examination. 

For    purposes   of  description  the    abdomen  may  be    divided 


\ 


Margin  of  ribs 


Crest  of  ilium 


Spine  of  pubes 

FIG.   18. — The  Abdomen  Divided  into  Quadrants 
and   the   Bony   Landmarks  Indicated. 

arbitrarily  into  four  regions,  by  two  lines,  one  a  vertical  line  pass- 
ing through  the  ensiform  cartilage,  the  umbilicus,  and  the  symphysis 
pubis,  and  the  other  passing  through  the  umbilicus  at  right  angles 
to  the  vertical  line.  The  four  regions  so  made  may  be  called  the 
right  upper  quadrant,  the  right  lower  quadrant,  the  left  upper 
quadrant,  and  the  left  lower  quadrant. 

On  observing  the  abdomen  one  notices  symmetry  or  asymmetry, 
distention  or    retraction,  increased  or  diminished '  motion  of  the 
abdominal  walls  on  respiration,  and  the  appearance  of  the  skin. 
5 


66  PHYSICAL  EXAMINATION 

To  detect  symmetry,  stand  at  the  foot  of  the  examining  table  and 
look  at  the  abdomen  from  below.  Tumors  of  the  ovary  as  well  as 
tumors  of  the  kidney  are  apt  to  cause  asymmetrical  enlargement 
of  the  abdomen;  whereas,  tumors  of  the  uterus  and  ascites  more 
commonly  produce  symmetrical  enlargement.  One  notes  bulging 
in  the  flanks  and  a  flattening  of  the  anterior  aspect  of  the  abdomen 
due  to  ascites,  or  to  lax  abdominal  walls,  with  or  without  an  abnor- 
mal amount  of  fat  in  the  panniculus  adiposus. 

A  tumor  rising  from  the  pelvis,  unless  of  great  size,  is  usually 
outlined  by  the  abdominal  walls.  In  ovarian  cysts  the  abdomen 
is  irregularly  ovoid  in  shape  with  its  point  of  greatest  protuberance 
below  the  umbilicus,  and  there  is  no  bulging  in  the  flanks.  In 
the  case  of  multilocular  cysts  the  loculi  may  be  distinguished  by 
sight  in  exceptional  cases  through  a  thin  abdominal  wall,  so  nodules 
of  a  malignant  growth  in  an  ovarian  cyst  can  sometimes  be  dis- 
tinguished by  the  eye.  Large  multiple  fibroids  also  show  occasion- 
ally through  the  skin  as  lumps  of  irregular  shape;  an  interstitial 
fibroid  forms  a  protuberance  of  a  smoother  outline  that  is  generally 
situated  in  the  median  line. 

Observe  the  movements  of  the  abdominal  walls.  The  normal 
movements  on  inspiration  and  expiration  extend  over  the  entire 
surface  from  ensiform  to  pubes.  In  cases  of  large  tumors  springing 
from  the  pelvic  cavity  the  movement  is  confined  to  the  epigastric 
region  if  the  distention  is  great,  also  if  there  are  adhesions  between 
the  tumor  and  the  parietes  there  may  be  motion  only  in  this  region. 
Sometimes,  when  there  arc  no  adhesions  present,  the  abdominal 
wall  can  be  seen  to  glide  up  and  down  over  the  surface  of  a  tumor 
of  moderate  size. 

Waves  of  peristalsis  in  the  intestines  may  be  noted  in  a  patient 
with  thin  flaccid  walls  and  retracted  abdomen,  also  pulsations  of 
the  abdominal  aorta.  In  pregnancy  the  situation  of  greatest  in- 
tensity of  fetal  movements  may  be  observed. 

Separation  of  the  recti,  due  to  distention  of  the  abdomen  during 
previous  pregnancies,  often  leaves  a  ventral  hernia  through  which 
a  tumor,  the  pregnant  uterus,  or  the  abdominal  contents  may 
protrude.  Palpation  of  the  abdominal  and  pelvic  organs  is  ren- 
dered most  easy  in  these  cases. 

The  appearance  of  the  skin  of  the  abdomen  is  of  interest  as 
showing  discolorations  from  blisters  and  counterirritants,  indica- 


INSPECTION  OF  THE  ABDOMEN 


67 


tions  of  previous  treatment,  also  the  presence  of  edema  or  skin 
diseases.  Enlargement  of  the  superficial  veins  indicates  pressure 
on  the  deeper  vessels.  Excessive  distention  of  the  abdomen 
renders  the  skin  white  and  glossy  in  appearance,  whereas,  when  the 
walls  are  lax,  the  skin  has  a  shriveled  or  puckered  look. 

The  linese  albicantes,  red  and  purple  when  recent,  and  white 
and  glistening  when  old,  are  to  be  looked  for  especially  over  the 
flanks.  They  indicate  previous  stretching  of  the  skin,  but  are  not 
pathognomonic  of  pregnancy,  as  they  occur  in 
virgins  who  have  grown  rapidly  and  then  lost 
subcutaneous  fat. 

Pigmentation  of  the  linea  alba  (linea  nigra)  and 
increase  of  pigment  about  the  umbilicus  and  lower 
abdomen  occur  in  some  women  during  a  first  preg- 
nancy. This  pigmentation  persists,  but  is  of  no 
diagnostic  importance  in  a  subsequent  pregnancy. 

When  the  patient  is  sick  in  bed  with  peritonitis, 
the  characteristic  way  in  which  she  holds  herself, 
with  knees  drawn  up  to  relieve  all  strain  on  the 
abdominal  parietes,  is  to  be  noted. 

Enteroptosis. — In  some  cases  it  is  advantageous 
to  put  the  patient  in  the  standing  position  for  the 
purpose  of  inspecting  the  abdomen;  especially  is 
this  desirable  in  suspected  ptosis  of  the  abdomi- 
nal viscera,  a  condition  often  associated  with 
uterine  disease. 

Here  we  must  inspect  not  the  abdomen  alone, 
but  the  entire  trunk.  The  patient  stands,  first,  facing  the  phy- 
sician, entirely  nude  except  for  a  sheet  held  by  a  nurse  draping 
the  lower  limbs  and  pubic  region.  Then  she  stands  so  that  he 
sees  her  in  profile.  In  typical  enteroptosis  one  notes  a  long,  nar- 
row thorax,  with  flat  and  sunken  epigastric  region.  The  waist  is 
long,  the  abdomen  is  prominent,  the  shoulders  are  rounded,  and 
when  seen  in  profile  the  lower  back  is  nearly  flat  instead  of  pre- 
senting, as  normally,  a  forward  curve,  with  shoulders  and  hips  well 
back  and  spine  bent  forward  in  the  lumbar  region.  There  is  gen- 
erally an  absence  of  adipose  tissue  in  these  patients  and  the  muscles 
are  apt  to  be  slender  and  flabby. 


FIG.  19.— The 
Body  Pose  in 
Enteroptosis. 


68  PHYSICAL  EXAMINATION 


7.  PALPATION  OF  THE  ABDOMEN 

To  palpate  the  abdomen  successfully,  the  patient  should  be  pre- 
pared as  for  inspection,  that  is,  in  the  dorsal  position  with  the  head 
slightly  raised  on  a  pillow,  all  clothing  loosened,  the  feet  supported, 
and  the  pubic  region,  thighs,  and  legs  covered  by  a  sheet.  The 
physician,  standing  on  the  patient's  right,  places  both  hands, 
warmed,  and  with  finger  nails  cut  short,  on  the  abdomen.  No 
abrupt  or  rapid  movements  should  be  made,  and,  for  the  purpose  of 
distracting  the  patient's  attention  and  thus  favoring  relaxation, 
it  is  advisable  at  this  juncture  to  ask  some  question  as  to  the  health, 
not  directly  referable  to  the  abdomen. 

By  care  and  patience  the  tendency  of  the  abdominal  muscles 
to  contract  when  stimulated  by  manipulation  may  be  overcome. 
Oftentimes  more  than  one  sitting  is  necessary  to  accomplish  this 
result,  and  in  this  event  the  diagnosis  must  be  held  in  abeyance 
until  after  a  second  examination.  It  is  better  to  make  two  or  more 
attempts,  except  in  urgent  cases,  rather  than  resort  to  an  examina- 
tion under  an  anesthetic,  because  with  increasing  experience  the 
physician  learns  an  added  amount  from  each  palpation,  and  hav- 
ing gained  the  patient's  confidence  and  treating  every  case  accord- 
ing to  her  individuality,  he  is  able  more  frequently  to  dispense  with 
an  anesthetic. 

The  utmost  gentleness  should  obtain  always.  The  harder  the 
pressure,  the  greater  the  resistance  of  the  abdominal  walls  and 
the  greater  the  blunting  of  the  physician's  tactile  sense.  Further- 
more, it  has  happened  several  times  in  the  experience  of  the  writer, 
that  a  student  novice  has  ruptured  a  thin-walled  or  nccrotic  ovarian 
cyst  or  a  circumscribed  collection  of  peritonitic  fluid,  by  too  vig- 
orous palpation. 

A  thin,  relaxed  abdominal  wall  permits  of  palpation  of  the 
promontory  of  the  sacrum,  and  the  pulsations  of  the  abdominal 
aorta  are  to  be  felt  distinctly.  The  anterior  superior  spines  and 
the  crests  of  the  ilia,  the  symphysis  pubis  and  the  borders  of  the 
ribs,  body  landmarks,  are  always  to  be  made  out.  Thick  and 
tense  abdominal  walls  interfere  with  palpation. 

It  is  well  to  have  a  definite  system  to  follow  in  palpating  the 


PALPATION  OF  THE  ABDOMEN  69 

abdomen.  Begin  with  the  lower  quadrants  and  proceed  to  the 
upper  quadrants.  (See  Figure  18,  page  65.)  By  making  firm 
but  gentle,  deep  pressure,  the  patient  at  the  same  time  taking  a 
deep  breath,  the  hands,  flat  on  the  abdomen,  are  brought  together 
and  a  fold  is  grasped  between  them  so  that  an  estimate  is  formed 
of  the  thickness  of  the  abdominal  walls  and  their  degree  of  tension. 
Avoid  as  far  as  possible  digging  into  the  flesh  with  the  tips  of  the 
fingers,  using  instead  the  palmar  surfaces  of  the  last  phalanges, 
the  location  of  the  trained  tactile  sense. 

We  may  learn  by  palpation,  of  the  presence  of  a  tumor,  also  its 
situation,  size,  shape,  mobility,  consistency,  and  point  of  attach- 
ment. We  determine  a  point  of  tenderness  on  pressure,  indicating 
localized  peritonitis.  In  a  majority  of  cases  we  may  palpate  the 
normal  kidneys,  more  easily  if  they  are  enlarged  or  displaced.  We 
palpate  the  edge  of  the  normal  or  enlarged  liver,  and  a  displaced 
liver,  as  in  enteroptosis,  also  a  distended  gall  bladder,  or  an  en- 
larged spleen.  A  loop  of  bowel  distended  with  feces  and  also  the 
distended  urinary  bladder  may  be  made  out  by  palpation. 

Suppose  a  tumor  is  present;  first  we  determine  its  situation 
by  making  gentlex  firm  pressure  with  both  hands,  noting  in  which 
quadrant  or  quadrants  of  the  abdomen  it  is  situated.  The  ab- 
dominal walls  should  move  with  the  hands  over  the  underlying 
organs  or  the  tumor.  Tumors  situated  in  the  structures  of  the 
abdominal  wall  move  with  the  wall  on  inspiration  and  expiration 
over  the  organs  underneath.  Tumors  of  the  abdominal  and  pelvic 
organs  that  arc  adherent  to  the  abdominal  parietes  limit  the 
motion  of  the  walls  on  respiration.  Exceptionally,  in  cases  where 
the  walls  are  lax  and  the  tumor  is  not  excessively  large,  the  physician 
is  able  to  pick  up  the  abdominal  wall  and  determine  if  it  is  adherent 
to  the  tumor  beneath.  All  the  abdominal  organs  normally  move 
more  or  less  during  respiration, — those  organs  nearer  the  diaphragm, 
as  the  liver  and  kidneys,  moving  the  most,  while  those  in  the 
bottom  of  the  abdomen  are  less  affected.  The  size  of  the  tumors 
can  be  learned  only  approximately.  It  is  to  be  borne  in  mind  that 
some  tumors  vary  in  size  at  different  times:  for  instance,  an 
ovarian  cyst  is  smaller  after  there  has  been  free  catharsis  from  the 
bowels,  and  a  fibroid  tumor  of  the  uterus  is  larger  just  before  the 
catamenia  and  smaller  just  after. 

The  shape  of  the  tumor  is  made  out  by  palpating  it  in  several 


70  PHYSICAL  EXAMINATION 

directions.     To  this  end  the  examiner  shifts  his  position  to  the 
left  side  or  to  the  foot  of  the  examining  table. 

The  mobility  of  the  tumor  is  ascertained  by  grasping  it  between 
the  two  hands  and  moving  it  about.  Changing  the  patient's 
position  to  the  lateral  position  may  cause  the  tumor  to  fall  by 
gravity  to  the  dependent  side.  Ovarian  tumors  tend  to  gravitate 
into  the  abdominal  cavity  if  the  patient  is  put  in  the  knee-chest 
position.  The  excursions  of  a  movable  tumor  show  us  something 
as  regards  adhesions  and  the  point  of  attachment  and  length  of 
the  pedicle.  Traction  on  the  pedicta  generally  causes  pain  re- 
ferred to  the  situation  of  the  pedicle. 

The  consistency  of  a  tumor  is  often  a  difficult  matter  to  pass  on. 
Waves  of  fluctuation  arc  made  out  by  a  combination  of  palpation 
and  percussion.  The  hand  of  an  assistant  is  placed,  ulnar  edge 
down,  in  the  longitudinal  axis  of  the  abdomen  and  firm  pressure  is 
made.  This  is  to  eliminate  the  wave  which  may  be  transmitted  by 
the  fat  of  the  abdominal  wall.  The  physician  taps  one  side  of  the 
abdomen  and  notes  with  the  other  hand,  placed  on  the  opposite 
side,  oscillations  which  may  be  transmitted  through  the  fluid. 
If  a  cyst  is  filled  so  that  the  fluid  is  under  great  pressure  and  if 
the  cyst  walls  are  thick,  the  fluid  waves  may  be  indistinguishable. 
So  also,  if  the  fluid  is  of  a  thick  consistency,  fluctuation  may  be 
absent. 

Peristaltic  contractions  of  a  piece  of  intestine  are  sometimes 
to  be  distinguished  and  also  the  rhythmical  contractions  of  a 
pregnant  uterus.  To  determine  either  of  these  it  is  necessary  to 
let  the  hand  rest  gently  on  the  abdomen  for  a  considerable  length  of 
time. 

The  point  of  attachment  of  a  tumor  may  be  learned  by  moving 
the  tumor  while  the  hand  is  held  on  a  neighboring  organ  and  noting 
whether  the  organ  moves  too,  or  by  moving  the  organ  and  noting 
the  behavior  of  the  tumor. 

Palpation  of  the  Kidneys. — Palpation  of  the  kidneys  is  best  done 
with  the  patient  in  the  dorsal  position.  The  physician  stands  at 
the  patient's  side  facing  toward  her  head,  his  left  hand  is  placed 
under  the  flank  and  his  right  hand  over  the  flank,  while  the  patient 
takes  a  deep  breath.  This  process  is  repeated,  the  hands  coming 
together  a  little  more  with  each  expiration.  Time,  gentleness,  and 
gradual  movements  are  important  factors  in  this  manipulation. 


PERCUSSION  OF  THE  ABDOMEN  71 

The  right  kidney,  being  a  little  lower  than  the  left,  is  more  accessible 
to  palpation.  With  practice  it  will  be  found  that  there  are  com- 
paratively few  cases, — and  these  patients  having  very  stout  and 
rigid-walled  abdomens, — in  which  the  lower  poles,  at  least,  of  the 
kidneys  can  not  be  felt. 

In  the  case  of  movable  kidney,  generally  the  entire  kidney  can 
be  outlined,  especially  where  it  is  enlarged.  Pressure  on  a  tuber- 
culous or  hydronephrotic  kidney  will  frequently  force  turbid 
urine  through  the  ureter  into  the  bladder.  If  the  bladder  has 
been  emptied  by  catheter  previous  to  the  examination  and  clear 
urine  obtained,  such  a  procedure  assists  materially  in  establishing 
the  diagnosis,  for  a  second  catheterization  following  palpation 
draws  off  cloudy  urine. 

To  determine  the  extent  of  the  downward  excursion  of  a  mis- 
placed kidney  the  flank  is  palpated  either  in  the  sitting  or  in  the 
standing  position.  In  the  sitting  position  the  patient  sits  on  the 
foot  of  the  table  with  her  feet  in  a  chair,  and  bends  forward  slightly. 
In  the  standing  position  she  stands  facing  the  table  and  about  a 
foot  from  it.  Placing  both  hands  on  the  table  she  leans  forward 
so  that  part  of  her  weight  is  taken  on  the  hands;  thus  the  abdom- 
inal muscles  are  relaxed.  This  manipulation  can  be  executed 
best  with  the  assistance  of  a  nurse  or  another  woman,  because  the 
patient  can  not  hold  up  her  loosened  clothing  and  bear  part  of  the 
weight  on  her  hands  at  the  same  time.  Personally,  I  have  learned 
to  place  the  chief  reliance  on  the  dorsal  position  for  palpation  of 
the  kidneys,  except  to  make  out  the  amount  of  extreme  downward 
excursion,  when  sometimes  the  standing,  and  at  others  the  sitting, 
position  gives  the  better  result. 

8.  PERCUSSION,  AUSCULTATION,  AND  MENSURATION  OF  THE 

ABDOMEN 

The  combination  of  palpation  and  percussion  for  the  detection 
of  fluid  waves  in  the  abdomen  has  been  described  in  the  discussion 
of  palpation. 

Percussion  is  best  practiced  with  the  patient  in  the  dorsal  position. 
By  it  we  determine  the  situation  of  the  lower  margin  of  the  liver- 
dullness,  the  area  of  stomach  and  colon  tympany,  splenic  dullness, 
the  dullness  due  to  fecal  accumulations  in  the  bowels  or  urine  in 


72  PHYSICAL  EXAMINATION 

the  bladder,  and  the  dullness  caused  by  free  fluid  in  the  peritoneal 
cavity  or  by  the  fluid  or  solid  constituents  of  a  tumor. 

Unfortunately  we  have  no  standard  of  comparison  in  percussion. 
We  can  not  compare  the  percussion  note  of  one  side  of  the  abdomen 
with  that  of  the  other,  and  the  conditions  are  constantly  varying, 
due  to  changeable  quantities  of  fluid,  solid  and  gaseous  matters 
in  the  stomach  and  bowels,  and  the  encroachment  of  one  organ  on 
another.  Also,  there  are  to  be  considered  the  variations  caused 
by  the  normal  mobility  of  the  abdominal  organs. 

Nevertheless,  percussion  is  a  valuable  adjunct  to  palpation. 
Its  chief  use  in  gynecological  diagnosis  is  in  differentiating  between 
ascites  and  a  cystic  ovarian  tumor.  In  the  case  of  ascites,  the  flanks, 
being  the  dependent  portion  of  the  abdominal  cavity  and  there- 
fore occupied  by  fluid,  are  dull  to  percussion.  The  intestines, 
filled  more  or  less  by  gas,  float  on  top  of  the  fluid,  and  give  an  area 
of  resonance  in  the  umbilical  region.  Shifting  the  position  of  the 
patient  to  one  side  sends  the  fluid  (unless  by  chance  it  is  walled 
off  by  adhesions)  to  the1  dependent  side,  and  the  resonance  is  to  be 
found  on  the  upper  side  and  flatness  below.  In  rare  cases,  when 
the  ascitic  fluid  greatly  distends  the  abdomen,  there  may  be  no 
change  in  the  area  of  dullness  on  shifting  the  position  of  the  patient. 

In  the  case  of  a  large  ovarian  cyst,  the  resonance  is  in  the  epi- 
gastric region,  the  intestines  having  been  forced  there  by  the  tumor 
and  the  dullness  is  over  the  area  occupied  by  the  tumor.  Change 
of  posture  does  not  alter  the  areas  of  dullness  and  resonance.  (See 
Figures  132  and  133.)  If  the  gut  has  a  short  mesentery,  the 
intestinal  resonance  may  be  in  the  upper  parts  of  the  flanks,  or, 
in  case  the  intestine  is  occupied  by  fluid  or  solid  fecal  matter,  there 
may  be  little  or  no  resonance,  the  entire  abdomen  being  dull  or 
flat  to  percussion.  A  large  deposit  of  fat  in  the  omcntum  may 
cause  dullness  in  any  situation. 

In  gastroptosis  one  detects  the  displaced  stomach  by  inflating  it 
with  gas  by  giving  the  patient  a  dram  of  bicarbonate  of  soda  in 
half  a  glass  of  water,  followed  by  half  a  dram  of  tartaric  acid  in 
another  half-glass  of  water.  Percussion  is  performed  with  the 
patient  in  the  dorsal  position  and  also  in  the  standing  position. 
The  lower  margin  of  the  liver  is  percussed  in  these  two  positions 
and  the  differences  of  level  noted. 

Auscultation  is  of  value  chiefly  in  diagnosing  pregnancy.     The 


AUSCULTATION  OF  THE  ABDOMEN  73 

detection  of  the  fetal  heart-sounds,  with  a  rate  entire  y  different 
from  that  of  the  maternal  pulse,  is  one  of  the  absolutely  distinctive 
signs  of  pregnancy.  They  are  seldom  discernible  before  the  twen- 
tieth week,  although  certain  observers  report  having  heard  them 
as  early  as  the  twelfth  week.  After  the  twenty-eighth  week  they 
should  almost  always  be  heard,  if  the  child  is  alive,  at  any  rate 
after  repeated  examinations.  Hydramnios  or  thick  abdominal 
walls  may  prevent  the  sounds  from  being  transmitted  to  the  ear. 
The  sounds  are  usually  heard  over  the  child's  back.  Therefore, 
since  left  positions  of  the  occiput  are  the  most  common,  the  heart- 
sounds  are  generally  to  be  heard  on  a  line  drawn  from  the  um- 
bilicus to  the  left  anterior  superior  spine  of  the  ilium. 

If  they  are  not  heard  in  this  region  the  entire  abdomen  should 
be  auscultated  carefully.  Changes  in  the  position  of  the  child  may 
make  the  sounds  audible  at  one  time  and  inaudible  at  another,  so 
that,  should  there  be  a  failure  to  hear  them,  more  than  one  exam- 
ination is  to  be  made.  Occasionally  the  child's  position  may  be 
changed  by  manipulation  for  purposes  of  auscultation,  so  that  its 
back  comes  against  the  abdominal  parietes  of  the  mother.  Some 
physicians  prefer  direct  auscultation,  with  the  ear  applied  to  the 
abdomen,  to  the  mediate  auscultation  of  the  stethoscope. 

The  binaural  stethoscope  is  the  best  means  for  detecting  the 
fetal  heart-sounds.  Its  mouth  should  be  moistened  to  do  away 
with  the  noise  generated  by  the  slipping  of  the  stethoscope  on  the 
skin.  Generally  the  lightest  possible  pressure  of  the  stethoscope 
on  the  skin  is  advisable,  and  to  this  end  it  is  best  to  let  it  rest  by 
its  own  weight  and  not  to  hold  it  with  the  fingers.  The  beating  of 
the  fetal  heart  (130  to  140  beats  a  minute)  has  been  likened  to  the 
ticking  of  a  watch  under  a  pillow.  To  make  the  diagnosis  sure, 
the  rate  should  be  counted  for  a  minute,  and  thus  it  is  differentiated 
from  the  maternal  pulse,  which  is  counted  by  the  physician's 
finger  on  the  mother's  radial  artery. 

The  uterine  souffle,  or  bruit  so  called,  is  an  intermittent  blowing 
sound  synchronous  with  the  patient's  pulse.  It  occurs  not  only 
in  pregnancy  but  also  in  fibroids  of  the  uterus  and  in  other  uterine 
and  even  ovarian  tumors,  and  is  probably  due  to  increased  circula- 
tion in  enlarged  blood-vessels.  It  is  of  no  special  diagnostic  im- 
portance. The  noises  made  by  gas  in  the  stomach  arid  intestines 
are  to  be  detected  bv  auscultation. 


74  PHYSICAL  EXAMINATION 

In  cases  of  peritonitis,  one  may  determine  by  this  means  whether 
the  peristaltic  movements  of  the  intestines  are  still  present.  Fric- 
tion sounds  made  by  the  rubbing  together  of  roughened  surfaces 
of  tumors  and  adjacent  structures  may  sometimes  be  heard,  also 
the  murmur  transmitted  from  an  abdominal  aneurysm. 

Mensuration  is  a  means  of  determining  the  rate  of  growth  of 
an  abdominal  tumor.  Exact  measurements  are  impracticable 
because  of  the  varying  state  of  the  bowels  as  to  distention  or 
relaxation,  and  also  because  of  the  yielding  nature  of  the  tissues 
and  the  mobility  of  the  tumors.  Nevertheless,  much  may  be 
learned,  in  cases  of  chronic  enlargement  of  the  abdomen,  by  making 
careful  measurements  at  repeated  examinations  several  weeks  or 
months  apart.  These  are  made  partly  with  a  tape  measure  and 
partly  with  a  pelvimeter,  and,  for  purposes  of  comparison,  all 
subsequent  measurements  should  be  made  under  as  nearly  similar 
conditions  as  to  time  of  day,  time  after  menstruation,  state  of  the 
bowels,  etc.,  as  possible.  They  should  always  be  made  with  the 
patient  in  the  same  position  and  with  all  clothing  loosened.  Very 
light  contact  pressure  with  the  tape  or  pelvimeter  on  the  skin  is  best. 

The  measurements  to  be  taken  are: — the  greatest  circumference; 
the  circumference  at  the  umbilicus ;  the  distance  from  the  cnsiform 
cartilage  to  the  symphysis  pubis;  from  the  umbilicus  to  the  an- 
terior superior  spine  of  the  ilium  on  each  side;  and  the  greatest 
diameter  of  the  abdomen  as  measured  with  the  pelvimeter,  the 
patient  standing,  one  point  of  the  pelvimeter  being  placed  over 
the  most  prominent  portion  of  the  abdomen,  and  the  other  over 
the  spinous  process  of  some  definite  counted  sacral  vertebra. 

Dr.  Howard  A.  Kelly  ("Medical  Gynecology,"  p.  17)  has  devised 
a  method  for  making  permanent  gauze  records  of  abdominal 
tumors  and  displaced  viscera.  The  patient  being  in  the  dorsal 
position,  the  physician  outlines  the  tumor  and  the  landmarks, 
such  as  anterior  superior  spines  of  the  ilia,  margins  of  the  ribs, 
symphysis,  and  umbilicus,  on  the  skin  of  the  abdomen  with  an 
aniline  pencil.  If  the  skin  does  not  take  the  pencil  marks  well, 
wet  it  with  a  little  alcohol.  Lay  a  plate  of  glass  over  the  abdomen 
and  on  it  place  a  piece  of  stiffened  gauze  (suisse,  nainsook,  or  organ- 
die). The  skin  markings  are  visible  through  the  glass.  Reproduce 
them  with  a  crayon  pencil  on  the  gauze.  File  away  the  gauze, 
labeled  with  the  patient's  name  and  the  date,  for  future  reference. 


FIG.  20. — A  Permanent  Gauze  Record  of  an  Abdominal  Tumor.     (Kelly.) 


75 


76  PHYSICAL  EXAMINATION 

The  X-rays  in  Diagnosis. — The  X-rays  arc  of  supplementary 
diagnostic  value  in  detecting  stone  in  the  ureter  or  kidney,  and  in 
determining  ptosis  of  the  stomach  and  intestines  when  these  organs 
are  filled  with  bismuth  in  suspension,  also  the  presence  of  bone  in 
tumors, — conditions  important  for  the  gynecologist  to  recognize. 
One  skilled  in  the  use  of  the  Roentgen  rays  should  be  called  in,  as 
the  neophyte  is  apt  to  be  misled  by  the  appearances  seen  in  the 
photographic  plates,  and  to  put  a  wrong  interpretation  on  their 
showings. 


CHAPTER  VII 
THE   PHYSICAL    EXAMINATION   (Concluded) 

III.  The  examination  (concluded):  9.  Instruments  and  their  use  in 
diagnosis,  p.  77:  General  remarks,  p,  77.  The  uterine  sound,  p.  78:  When 
to  pass  it,  p.  78;  Methods  of  passing,  p.  79;  Facts  to  be  determined  by  the 
use  of  the  sound,  p.  80;  Cautions,  p.  82.  The  uterine  probe,  p.  82.  The 
uterine  dressing  forceps,  p.  83.  The  uterine  tenaculum,  p.  84.  The 
vulsellum,  or  double  tenaculum  forceps,  p.  84.  The  vaginal  speculum,  p. 
85:  The  bivalve,  or  duckbill  speculum,  p.  85;  The- Neugebauer  bivalve 
speculum,  the  Ferguson  speculum,  the  Simon  speculum,  and  the  Edebohls 
speculum,  p.  86;  The  Sims  speculum,  p.  87.  The  Hunter  depressor,  p. 
88.  The  Emmet  curette  forceps,  p.  89.  The  uterine  curette,  p.  90. 
Curetting,  p.  90:  Dangers  of  curetting,  p.  93.  Digital  exploration  of  the 
uterine  cavity,  p.  94.  Pelvimetry,  p.  95:  External  or  Baudelocque's 
conjugate  diameter,  p.  96;  The  oblique  conjugate  diameter,  p.  97;  The 
transverse  diameter,  p.  98;  The  transverse  diameter  of  the  outlet,  p.  98. 
The  capacity  of  the  pelvic  cavity,  p.  98;  The  oblique  diagonal  diameters, 
p.  98. 

THE  EXAMINATION    (Concluded) 
9.  INSTRUMENTS  AND  THEIR  USE  IN  DIAGNOSIS 

IN  a  majority  of  gynecological  diseases  the  diagnosis  is  made 
without  the  use  of  instruments.  They  are  not  the  most  important 
part  of  the  physician's  equipment.  No  matter  how  ingeniously 
constructed,  and  be  they  ever  so  well  adapted  to  their  uses,  instru- 
ments in  these  days  can  not  take  the  place  of  the  educated  touch. 
The  physician,  particularly  the  American  physician,  with  his  native 
mechanical  bent,  although  mindful  of  the  revolutionizing  of 
gynecology  by  the  speculum  (which  his  countryman,  J.  Marion 
Sims,  gave  to  the  world),  should  forswear  the  wiles  of  the  instru- 
ment-maker and  devote  his  attention  to  training  his  touch,  leaving 
instruments  to  the  last. 

The  immediate  followers  of  Sims  and  Emmet  were  so  pleased 
with  tht'  newly  discovered  vaginal  speculum  and  with  their  ability 
to  inspect  the  vagina  by  its  skillful  use,  that  they  were  quite  content 

77 


78  PHYSICAL  EXAMINATION 

to  rest  their  diagnoses  of  uterine  disease  on  what  they  saw  through 
the  speculum.  Hence  it  followed  that  for  the  time  other  means  of 
investigation  were  slighted  and  only  in  recent  years  has  the  pro- 
fession escaped  from  the  thrall  of  the  speculum. 

Out  of  a  number  of  instruments  each  examiner  and  operator 
will  have  his  personal  preference  for  those  which  seem  best  to 
serve  his  needs.  My  full  kit  of  instruments  is  to  be  found  in 
Chapter  IV.,  page  28. 

The  Uterine  Sound.— The  uterine  sound,  although  employed  less 
and  less  as  skill  in  the  bimanual  touch  increases,  is  on  the  whole 
the  most  valuable  of  the  instruments  used  in  diag- 
nosis. In  the  days  of  Peaslee,  Simpson,  and  Sims, 
the  use  of  the  sound  was  much  abused,  as  the  other 
means  of  diagnosis  had  not  been  perfected  at  that 
time.  The  student  was  taught  to  pass  the  sound  in 
nearly  all  cases  of  uterine  disease,  and,  as  aseptic 
methods  were  unknown,  the  results  to  the  patient 
were  too  often  disastrous.  Not  only  was  the  sound 
passed  into  the  uterine  cavity,  but  malpositions  of 
the  uterus  were  forcibly  corrected  by  this  means,  thus 
adding  trauma  to  infection.  At  the  present  time  the 
sound  is  employed  to  confirm  a  diagnosis  made  by  the 
bimanual  touch,  and  in  certain  rare  conditions  to  make 
a  diagnosis  where  the  touch  can  not  be  used. 

The  sound  is  to  be  preferred  to  the  probe  because 
the  slightly  larger  end  of  the  sound  will  slip  over 
The  I'turine     irregularities  in  the  mucous  membrane  lining  the  cavi- 
Souiul.  ties  of  the  cervix  and  the  body  of  the  uterus,  while 

the  tip  of  a  probe  will  catch  in  them.  A  sound  of 
small  caliber  made  of  flexible  copper,  with  a  knob  at  the  distal  end, 
one  side  of  the  handle  being  rough  and  the  other  smooth,  should  be 
chosen.  One  side  of  the  handle  is  made  rough  so  that  the  operator 
may  be  informed  as  to  the  direction  taken  by  the  point  of  the  bent 
instrument  when  sounding  a  deep  and  tortuous  uterine  cavity  or 
sinus.  The  sound  may  be  graduated  in  inches  or  centimeters, 
according  to  the  preference  of  the  physician.  It  is  easier  to  keep 
it  clean  if  it  has  no  notches.  The  measurements  are  taken  by  mark- 
ing the  depth  to  which  it  has  entered  the  uterus,  by  means  of  the 
finger  tip  held  against  the  sound,  or  the  dressing  forceps  grasping 


79 

the  sound  at  the  external  os  and  then,  on  withdrawing  it,  compar- 
ing the  measurements  with  a  measured  scale  on  the  table  on  which 
the  instruments  are  placed. 

Before  passing  the  sound  the  vagina  must  be  cleansed  in  every 
case.  We  do  not  know  what  bacterial  growth  may  be  present  hi 
the  vagina.  Assuming  that  there  are  no  pathogenic  organisms 
present  under  normal  conditions,  some  are  introduced  from  the 
external  genitals  in  the  course  of  the  vaginal  touch,  which  always 
precedes  the  use  of  the  sound.  To  cleanse  the  vagina,  swab  it  out 
several  times  with  pledgets  of  absorbent  cotton  held  in  the  uterine 
dressing  forceps  and  dipped  in  a  warm  solution  of  creolin  and 
water  (one  per  cent). 

The  sound  may  be  passed  (1)  bimanually,  the  patient  being  in 
the  dorsal  position.  To  do  this  the  physician  seizes  a  piece  of 
absorbent  cotton  in  the  uterine  dressing  forceps  held  hi  his  right 
hand,  and  carries  it  through  the  warm  creolin  solution;  now  de- 
pressing the  patient's  perineum  with  his  left  forefinger  in  the 
vagina,  he  swabs  out  the  entire  vagina,  repeating  the  process 
several  times.  Laying  down  the  dressing  forceps  he  takes  up  the 
sound.  The  situation  of  the  external  os  is  determined  with  the 
tip  of  the  left  forefinger,  and  the  knob-like  end  of  the  sound  is 
carried  along  the  left  forefinger  until  it  enters  the  os.  The  further 
manipulations  are  directed  by  the  information  as  to  location,  axis 
and  shape  of  the  uterus,  gained  by  the  bimanual  touch.  It  is 
customary  to  bend  slightly  the  distal  two  inches  of  the  sound 
toward  the  roughened  side  of  its  handle.  The  sound  is  held  lightly 
in  the  right  hand  and  allowed  to  slide  in  by  its  own  weight.  For- 
cible movements  are  absolutely  contraindicated  and  unnecessary. 
The  physician  who  uses  force  thereby  demonstrates  that  he  has 
failed  in  his  bimanual  touch.  If  the  sound  does  not  pass  readily 
it  should  be  withdrawn  and  the  end  bent  at  a  different  angle  and 
reintroduccd.  Remember  that  the  barriers  to  the  introduction 
of  the  sound  are  at  the  external  and  internal  ora.  The  internal  os 
is  always  closed  except  when  blood  is  passing  out  of  the  uterine 
cavity,  after  labor,  or  in  certain  pathological  states. 

In  some  cases  where  the  uterus  is  sharply  flexed,  and  when  it  is 
high  in  the  pelvis,  the  cervix  may  be  grasped  with  a  tenaculum 
and  drawn  toward  the  vulva  to  facilitate  the  introduction  of  the 
sound.  The  tenaculum  should  be  a  single  one;  introduced  into  the 


SO  PHYSICAL  EXAMINATION 

cervical  canal,  not  a  double  tenaculum,  which  makes  two  holes  in 
the  cervix  and  may  start  a  hemorrhage  and  cause  pain. 

The  sound  may  be  passed  (2)  by  sight.  For  this  purpose  the 
patient  is  in  the  dorsal,  the  Sims,  or  the  knee-chest  position.  If 
in  the  dorsal  position  the  bivalve  speculum  is  introduced  and  the 
vagina  cleansed.  The  cervix  is  steadied  with  the  tenaculum  and 
the  sound  inserted  in  the  uterine  cavity.  If  in  the  Sims  position 
the  Sims  speculum  is  introduced,  and  the  manipulations  are  as 
in  the  dorsal  position.  If  in  the  knee-chest  position,  the  Sims 
speculum  is  introduced  and  the  vagina  balloons  with  air,  the  uterus 
falling  forward  toward  the  abdomen.  In  this  position  it  will  be 
found  necessary  generally  to  seize  the  cervix  with  a  tenaculum  and 
raise  it  before  the  sound  will  enter. 

The  uterine  sound  shows  the  depth  and  direction  of  the  uterine 
canal,  the  size  of  the  external  and  internal  ora,  the  shape  of  the 
uterine  cavity,  situation  of  lacerations  of  the  cervix,  irregularities 
of  the  mucosa,  the  situation  of  the  pedicle  of  a  uterine  polyp  or 
submucous  fibroid,  the  tonicity  of  the  uterine  walls,  and,  by  biman- 
ual  touch  with  the  sound  in  the  uterus  and  the  hand  on  the 
abdomen,  the  thickness  of  the  uterine  walls. 

In  passing  the  sound  one  measures  the  distance  from  the  ex- 
ternal os  to  the  internal  os  where  the  tip  of  the  sound  catches,  and 
thus  estimates  the  length  of  the  cervical  canal.  The  remaining 
distance  from  the  internal  os  to  the  fundus  gives  the  depth  of  the 
uterine  cavity  proper.  In  this  way  are  distinguished  the  uterus 
of  the  little  girl,  the  so-called  infantile  uterus  with  its  long  cervix 
and  short  body,  and  hypertrophic  elongation  of  the  cervix,  an 
exaggeration  of  the  infantile  uterus;  the  atrophic  uterus  of  old  age 
with  small  body  and  shortened  cervix;  lactation  atrophy,  and  the 
uterus  deprived  of  its  cervix  by  amputation. 

The  uterine  cavity,  as  a  whole,  is  increased  in  size  in  pregnancy, 
subinvolution,  hypertrophic  elongation  of  the  cervix,  and  new 
growths.  It  is  diminished  in  atrophic  conditions, — either  failure 
of  development  or  acquired  atrophy, — in  inversion,  and  in  new  for- 
mations encroaching  on  the  cavity. 

In  investigating  the  direction  of  the  uterine  canal  it  must  be 
borne  in  mind  that  the  cervical  canal  may  extend  in  one  direction 
while  the  uterine  cavity  is  at  an  angle  to  it,  as  in  anteflexion  and 
retroflexion.  Inflammatory  exudate  or  new  growths  in  the  neigh- 


INSTRUMENTS  AND  THEIR  USE  81 

borhood  of  the  uterus,  by  causing  displacement,  may  alter  the 
direction  of  the  canal. 

Stenosis  of  the  external  os  is  common  in  certain  forms  of  ante- 
flexion  where  we  find  the  so-called  "pinhole  os,"  in  senile  atrophy, 
and  following  improperly  performed  operations  on  the  cervix. 
False  stenosis  of  the  internal  os  is  apparent  in  many  cases  of 
anteflexion,  the  sound  passing  when  the  uterus  has  been  straight- 
ened by  traction  on  the  cervix  with  a  tenaculum.  True  stenosis 
is  found  after  injuries  of  the  internal  os  due  to  too  vigorous  curetting 
or  to  steaming;  from  inflammation  in  the  tissues  in  this  neighbor- 
hood, as  in  cases  of  cancer  of  the  cervical  canal  (adenocarcinoma) ; 
in  senile  atrophy;  and  it  may  be  congenital,  as  in  hematometra. 

Both  the  internal  os  and  the  external  os  may  be  enlarged  in 
subinvolution  and  as  a  result  of  laceration. 

It  is  important  to  determine  whether  the  internal  os  also  is 
lacerated  in  cases  where  there  are  lacerations  in  the  external  os. 
This  is  done  by  the  sense  of  touch  communicated  through  the 
sound.  The  situation  and  extent  of  laceration  are  determined 
partly  by  recognizing  the  landmarks  in  the  mucosa  of  the  cervical 
canal  in  the  form  of  the  arbor  vitse  and  by  trying  to  reconstruct 
the  cervix  in  its  original  form  by  rolling  the  everted  edges  together 
with  tenacula,  also  by  placing  the  sound  over  the  arbor  vitas  with 
its  tip  at  the  middle  of  the  fundus  and  noting  whether  a  laceration 
is  on  one  or  both  sides  of  the  sound.  (See  Chapter  XIII.,  p.  209.) 
The  sound  gives  a  good  idea  of  the  shape  and  size  both  of  the 
cervical  canal  and  of  the  uterine  cavity  proper. 

The  physician  while  passing  the  sound  should  keep  in  mind 
always  the  shape  of  the  normal  uterine  cavity  (see  Figures  64,  67, 
and  68,  pp.  166,  171,  172),  an  isosceles  triangle,  having  as  bound- 
aries front  wall,  back  wall,  fundus,  and  internal  os.  There  are 
no  side  walls,  but  in  their  place  are  the  two  furrows  formed  by  the 
meeting  of  the  front  and  back  walls,  beginning  below  at  the  internal 
os  and  ending  above  in  the  orifices  of  the  Fallopian  tubes. 

The  internal  os  being  relaxed  or  dilated,  the  properly  bent  sound 
is  passed  lightly  and  methodically  over  anterior  wall,  posterior 
wall,  fundus,  and  lateral  furrows,  detecting  fungosities  or  inequal- 
ities in  the  mucosa,  or  a  pedunculated  growth.  The  last  is  veiy 
difficult  to  do,  and  is  not  possible  in  all  cases.  It  is  surprising, 
however,  how  much  may  be  learned  by  training  the  sound-touch. 
6 


S2  PHYSICAL  EXAMINATION 

Hy  sound-toucli  thr  firm,  clastic  resistance  of  the  healthy  uterus 
may  he  differentiated  from  the  sclerosed  tissues  of  suhinvolution 
or  the  soft  tissues  of  the  septic  uterus. 

\Yith  the  sound  in  the  uterus  and  the  fingers  on  the  abdomen  or 
with  a  finger  in  the  rectum,  it  is  possible  sometimes  to  estimate  the 
thickness  of  the  uterine  walls. 

Cautions. — The  greatest  caution  is  to  be  exercised  in  passing 
the  sound  in  infectious  cases,  especially  in  gonorrhea,  because  the 
sound  will  carry  the  infective  bacteria  beyond  the 
natural  barriers  at  the  external  and  internal  ora.  Also 
in  cases  of  septicemia  and  advanced  cancer,  the  sound 
should  be  used  with  circumspection  because  of  the 
danger  of  perforation  which  is  most  easily  made  under 
these  conditions,  the  uterine  structure  often  being  so 
soft  as  to  offer  practically  no  resistance  to  the  pass- 
age of  the  sound  through  it.  Perforation  occurs  oc- 
casionally under  such  conditions  in  the  hands  of  the 
most  careful.  Never  pass  the  sound  into  the  uterine 
cavity  without  first  asking  the  patient  the  date  of  her 
last  menstruation.  Make  this  an  invariable  rule,  and, 
not  forgetting  the  possibility  of  prevarication,  and 
also  having  fresh  in  mind  the  result  of  the  bimanual 
examination, — the  invariable  precursor  of  the  use  of 
any  instrument, — you  will  avoid  making  that  most 
serious  of  all  gynecological  mistakes,  the  sounding  of 
the  pregnant  uterus. 
1 IG-  :  The  misplaced  uterus  should  never  be  replaced 

pr  be  with  the  sound,  a  practice  much  in  vogue  twenty 

years  ago.  If  the  uterus  is  freely  movable,  not  held 
by  adhesions,  it  can  always  be  replaced  by  bimanual  manipulation 
together  with  traction  by  a  tenaculum  in  the  cervix,  making  use 
of  one  or  more"  of  the  various  gynecological  positions.  One  at- 
tempt should  not  discourage.  More  favorable  conditions  may 
obtain  at  another  time. 

Besides  its  use  in  the  uterus  the  sound  may  be  used  to  investigate 
the  bladder — its  situation,  as  in  prolapse  of  the  uterus  and  in 
tumors;  also  the  situation  of  sensitive  areas  and  the  presence  of 
stone  or  phosphatic  deposits  in  the  bladder. 

The  Uterine  Probe. — The  uterine  probe  has  the  same  uses  as  the 


INSTRUMENTS  AND  THEIR  USE 


surgical  probe,  and  besides  having  a  handle  and  a  long  shaft,  it 
can  be  used  to  investigate  the  interior  of  small  uterine  canals,  and 
may  be  bent  to  conform  to  tortuous  uterine 
interiors  or  long  sinuses.  The  probe  supple- 
ments the  sound,  but  as  an  aid  to  diagnosis 
should  not  supplant  it. 

The  Uterine  Dressing  Forceps. — My  pref- 
erence for  a  dressing  forceps  is  one  made 
on  the  scissors  principle,  as  this  seems  best 
to  supplement  the  hand  in  uterine  manipula- 
tions. The  forceps  known  as  Bozeman's, — 
detachable  blades  with  double  curve,  catch, 
and  serrated  jaws,— makes  one  of  the  most 
useful  instruments  known  to 
gynecological  art.  With  it  we 
not  only  grasp  pledgets  of  cot- 
ton with  which  to  wipe  away 
the  discharges  and  cleanse  the 
vagina,  but  also  remove  a  bit 
of  stringy,  tenacious  discharge 
from  the  os  uteri,  or  pieces  of 
tissue  from  the  os  or  vagina  for 
microscopic  or  bacteriological 
examination. 

By  grasping  with  the  for- 
ceps the  uterine  sound  while 
in  the  uterus  at  a  point 
where  it  projects  from  the 

external  os,  the  depth  of  the  uterine  cavity  is 
measured  on  a  clean  towel  when  the  sound  is  with- 
drawn. 

The  curves  in  the  blades  of  the  instrument  permit 
of  its  entering  the  uterine  cavity  or  a  sinus  while  the 
hand  which  holds  it  does  not  obstruct  the  operator's 
view.     Being  made  on  the  scissors  principle,  levers 
of  the  first  class  with  the  fulcrum    some   distance 
from  the  jaws,  one  is  able   often  to  open  the  jaws  in   a  cavity 
(uterine  cavity  or  sinus),  after  passing  through  a  narrow  opening 
(internal  os),  or  skin  entrance, — something  that  a  forceps  made 


FIG.    23.— Uterine 
Dressing  Forceps. 


FIG.  24.— 
Uterine  Ten- 
aculum. 


PHYSICAL  EXAMINATION 


on  the  principle  of  the  Sims  uterine  dressing  forceps,  levers  of  the 
third  class,  will  not  do. 

In  an  emergency  the  Bozeman  dressing  forceps  may  be  used  as 
a  hemostatic  forceps.  The  jaws  may  be  wound  with  absorbent 
cotton  and  thus  used  to  make  applications  to  the  interior  of  the 
uterus  or  a  sinus,  and  the  forceps  may  be  used  also  to  hold  nitrate- 
of-silver  pencils  for  cauterizing  granulations. 

The  Uterine  Tenaculum. — This  is  to-day  a  neglected  instrument. 
When  used  in  days  gone;  by  to  manipulate  silver  wire,  the  tenac- 
ulum  was  indispensable.  The  form  of  tenac- 
uluni  devised  by  Emmet  and  Sims  for  shoul- 
dering silver  wire  is  the  best  for  general  use — 
i.e.,  one  with  a  right-angled  end,  instead  of  a 
hook,  for  the  reason  that  it  holds  the  tissues  at 
the  point  where  :t  is  introduced, — is  less  likely 
to  tear  not  only  the  tissues  of  the  patient  but 
the  operator's  finger,  and  it  is  more  readily 
withdrawn  from  the  tissues  when  desired.  It 
should  be  introduced  into  diseased  tissue  when 
possible  and  does  less  damage  and  stays  in 
place  better  in  the  hard  resistant  mucosa  of  the 
cervical  canal  than  in  the  friable  mucous  mem- 
brane covering  the  vaginal  portion  of  the  cer- 
vix. 

Although  the  double  tenaculum  forceps,  or 
vulsellum,  holds  more  firmly  than  the  single 
tenaculum,  the  single  one  makes  but  one  punc- 
ture, causes  less  pain  and  no  hemorrhage,  and 
is  to  be  preferred  in  the  routine  of  examina- 
tions. 

Tenacula  are  of  immense  benefit  in  diag- 
nosis, in  steadying  and  drawing  down  the  cer- 
vix both  for  the  bimanual  examination  and 
for  inspection,  in  rolling  together  the  lips  of  a  torn  cervix  to  estimate 
the  situation  and  extent  of  the  tears,  to  reconstruct  the  lacerated 
perineum  by  hooking  the  landmarks  and  drawing  them  together, 
and  in  seizing  and  fixing  a  portion  of  cervical  tissue  to  be  removed 
for  the  purpose  of  microscopical  diagnosis.  The  slender  tenaculum 
does  not  bruise  the  tissues  as  does  the  tissue  forceps. 


F»;.  25.— Vulsellum 
Forceps. 


INSTRUMENTS  AND  THEIR  USE  85 

The  Vulsellum  or  Double  Tenaculum  Forceps. — In  choosing  an 
instrument  of  this  sort  one  should  aim  at  having  it  not  too  heavy 
and  yet  with  steel  enough  to  prevent  the  blades  springing  apart. 
The  so-called  American  bullet  forceps  with  two  points,  and  having 
a  check  on  one  blade  that  prevents  the  blades  crossing,  is  excellent 
and  most  useful.  Vulsella  made  after  the  principle  of  Museaux's 
forceps  (four  points),  or  the  French  heavy  vulsella  (four  or  more 
points),  are  useful  in  the  morcellation  of  fibroid  tumors  and  the 
removal  of  cancer,  but  have  no  place  in  diagnosis.  The  double 
tenaculum  forceps  is  useful  in  holding  the  cervix  during  dilatation 
when  it  is  necessary  to  have  a  firmer  hold  than  the  single  tenaculum 
will  give,  and  in  seizing  peduriculated  tumors  in  the  vagina,  also 
for  holding  and  drawing  down  the  uterus  while  practicing  the 
bimanual  touch  to  determine  the  relation  of  a  tumor  to  this  organ. 
(See  Figure  126.) 

The  Vaginal  Speculum. — As  has  been  said  previously,  most  of  the 
diagnosis  in  uterine  diseases  is  made  by  the  sense  of  touch.  The 
vaginal  speculum  offers  us  a  view  of  the  vagina  and  vaginal  portion 
of  the  cervix.  Of  the  multitude  of  different  forms  of  specula  to 
be  had  of  the  instrument  makers,  the  most  generally  useful  are  the 
bivalve  and  the  Sims.  The  Edebohls  speculum  with  weight 
attached  is  for  use  in  curetting  and  manipulations  performed  with 
the  patient  anesthetized.  In  children  a  good  view  of  the  vagina 
may  be  obtained  through  a  Kelly  cystoscope,  using  as  large  a  one 
as  will  go  through  the  vaginal  introitus  without  injuring  the  hymen, 
the  patient  being  in  the  knee-chest  position. 

The  Bivalve  or  Duckbill  Speculum. — There  are  many  good  forms 
of  this  speculum  on  the  market.  The  writer  prefers  those  called 
by  the  names  of  Brewer  and  Graves,  because  of  their  simplicity 
and  usefulness  under  varying  conditions.  More  than  one  speculum 
should  be  in  every  kit  for  the  reason  that  vaginae  vary  so  in  size. 
With  a  girl  having  a  narrow  vagina  and  a  not  easily  dilatable  hymen, 
a  small  speculum  is  called  for,  whereas,  for  a  woman  having  ex- 
tensive injuries  of  the  pelvic  floor  and  perineum  and  lax  and 
redundant  vaginal  walls,  a  large  speculum  is  a  necessity.  The 
patient  is  in  the  dorsal  position.  To  introduce  the  bivalve  speculum 
the  left  forefinger  is  anointed  with  lubrichondrin  and  both  valves 
of  the  speculum  are  smeared  with  it.  The  forefinger  is  introduced 
into  the  vagina  as  in  making  the  digital  examination,  the  perineum 


SO  PHYSICAL  EXAMINATION 

is  depressed,  and  the  speculum  introduced,  the  slit  between  the 
blades  being  vertical.  Before  the  speculum  has  reached  its  deepest 
point  of  entrance  it  is  turned  so  that  the  short  blade  is  above  and 
the  long  blade  behind.  By  means  of  the  lever  connected  with  the 
handle  of  the  speculum  the  blades  are  separated  until  the  cervix 
is  engaged  between  their  ends,  then  they  are  held  in  place  by  the 
set-screw  on  the  handle.  Some  bivalve  specula,  such  as  the  Graves, 
are  provided  with  a  second  set-screw  with  which  to  hold  the  sepa- 
rated bases  of  the  blades,  thus  increasing  the  spread  of  the  specu- 
lum at  the  introitus  vagiiur,  and  adding  to  its  usefulness  in  cases 
of  roomy  vagimr. 

Care  must  be  exercised,  in  handling  the  bivalve  speculum,  not  to 
pinch  folds  of  the  vagina  and  the  labia  minora  between  the  bases 
of  the  blades.  This  is  most  easy  to  do  when  the  vagina  is  lax  and 
the  labia  minora  long.  One  objection  to  the  bivalve  speculum  is 
that  its  blades  cover  both  the  anterior  and  posterior  walls  of  the 
vagina,  thereby  obscuring  them  from  view.  This  defect  may  be 
overcome  in  some  cases  by  turning  the  speculum,  first  having 
loosened  the  lever  holding  the  blades,  so  that  the  blades  are  on 
either  side  of  the  vagina.  The  cervix  is  to  be  brought  into  view, 
if  it  does  not  readily  present,  by  hooking  a  tenaculum  in  the  os  and 
drawing  the  cervix  downward. 

The  Neugebauer  bivalve  speculum  and  the  Ferguson  cylindrical 
speculum  are  used  by  some  gynecologists.  The  latter  covers  the 
entire  vagina  and  is  of  little  value  in  diagnosis.  The  former  re- 
quires much  skill  in  handling  to  prevent  pinching  the  vagina  or 
labia,  and  when  in  place  has  no  advantage  over  the  duckbill  specu- 
lum. 

There  are  various  specula  for  use  with  the  patient  in  the  dorsal 
position  that  depress  the  perineum  and  posterior  wall  without 
covering  the  anterior  wall,  such  as 

The  Simon  speculum,  which  is  one-half  of  a  Sims  speculum. 
These  specula  are  chiefly  useful  in  operative  procedures  where  the 
patient  is  anesthetized  and  is  not  called  upon  to  endure  the  dis- 
comtort  caused  by  prolonged  traction  on  the  perineum.  For 
operative  procedures  the  simplest  and  best  speculum  of  this  class 
is  (he  Edcholdx  speculum  with  a  solid  flattened  weight  weighing 
about  a  pound  and  fitted  with  a  hook,  instead  of  the  little 
pail  usually  sold  with  the  speculum.  The  weight  is  made  flat  so 


INSTRUMENTS  AND  THEIR  USE 


87 


FIG.  26. — Brewer  Bivalve  Speculum. 


that  it  does  not  take  up  useful  space  at  the  end  of  the  operating 
table.     A  weight  may  be  improvised  easily  out  of  a  piece  of  lead 
pipe  hammered  flat  and   per- 
forated to  take  a  hook  made 
out    of    a  piece  of  stout  iron 
wire. 

The  Sims  Speculum. — This, 
when  given  to  the  profession  a 
generation  and  a  half  ago  by  J. 
Marion  Sims,  transformed  the 
art  of  gynecology,  and  is  to  be 
used  only  with  the  patient  in 
the  Sims  position  or  in  the 
knee-chest  position. 

The  orthodox  method  of  pass- 
ing the  Sims  speculum  is  as  fol- 
lows:— The  operator  holds  the 
speculum  by  the  unused  blade 
in  his  left  hand  arid  places  the 

well-anointed  forefinger  of  the  right  hand,  along  the  blade  which 
is  to  be  used,  with  the  palmar  surface  of  the  finger  fitting  the  con- 
cavity and  the  tip  projecting  just  beyond  the  end  of  the  blade. 

The  tip  only  of  the  finger  enters  the 
vulvar  cleft,  and  while  the  back  of 
the  forefinger  protects  the  sensitive 
anterior  wall  of  the  vagina  and  in- 
troitus,  the  blade  is  pushed  into  the 
vagina  by  pressure  from  the  thumb 
of  the  right  hand  on  the  base  of  the 
blade,  the  unused  blade  being  at 
the  same  time  transferred  from  the 
operator's  left  hand  to  the  right 
hand  of  an  assistant. 

Another  arid  preferable  way  is  to 
anoint  the  left  forefinger  as  for  a 
vaginal  examination,  except  that 

the  palmar  as  well  as  the  dorsal  surface  of  the  finger  is  smeared 
with  the  lubricant,  then,  hooking  the  finger  about  the  blade  of  the 
speculum,  anoint  it  from  base  to  tip.  Finally,  pass  the  same 


FIG.  27. — Graves  Bivalve  Speculum. 


88  PHYSICAL  EXAMINATION 

finger  over  the  vulvar  cleft,  introduce  its  tip  into  the  vagina,  and 
carry  hack  the  perineum  far  enough  to  allow  the  tip  of  the  specu- 
lum to  enter.  In  pushing  the  speculum  home  the  direction  of  the 
vagina  is  to  be  borne  in  mind,  its  axis  being  not  straight  upward 
in  the  axis  of  the  patient's  body,  but  directed  backward  toward 
the  sacrum. 

The  use  of  the  Sims  speculum  necessitates  an  assistant,  except 
for  a  most  cursory  examination.  The  assistant  stands  on  the  left 
side  of  the  table  at  the  patient's  back  and  faces  sotuarely  the 
physician,  who  is  seated  in  the  chair;  with  all  the  fingers  of  the 
left  hand  the  assistant  raises  the  labium  ma  jus  on  the  upper,  right 
side,  holding  it  against  the  buttock  with  the  hand  flat,  not  with 
the  ends  of  the  fingers  dug  into  the  flesh.  The  assistant's  left  arm 
rests  on  the  patient's  right  thigh.  The  right  hand  receives  the 


Fio.  28.— Sims  Speculum. 

unused  blade  of  the  speculum  after  the  other  blade  has  been  settled 
in  the  proper  place  in  the  vagina.  The  simplest  method  of  holding 
the  speculum,  and  the  easiest  for  the  novice  to  learn,  is  to  grasp 
the  unused  blade  with  four  fingers  of  the  right  hand,  the  palm  of  the 
hand  being  upward.  (See  Fig.  11,  page  .53.) 

YVith  the  speculum  in  position  air  enters  the  vagina  and  the 
pelvic  contents  gravitate  toward  the  abdomen.  Nothing  but  the 
posterior  wall  of  the  vagina  being  covered,  a  nearly  unobstructed 
view  of  the  vagina  is  afforded.  By  moving  the  speculum  in  or  out 
or  turning  the  tip  from  side  to  side,  all  parts  of  the  vagina  may  be 
brought  into  view.  If  the  vaginal  walls  are  redundant  some  sort  of 
a  depressor  will  be  found  useful.  For  this  purpose  the  best  instru- 
ment is 

The  Hunter  Depressor. — It  should  have  a  flexible  copper  shank, 
and  a  large  and  a  small  end,  and  should  be  silver-plated.  With  it 


INSTRUMENTS  AND  THEIR  USE 


89 


FIG.  29. — Hunter  Vaginal  Depressor. 


one  pushes  out  of  the  field  of  vision  the  obstructing  folds  of  the 
vagina.  The  Hunter  depressor  has  an  advantage  over  the  Sims 
ring-shaped  depressor  ijn 
that  its  polished  silver 
surface  reflects  light  and 
therefore  aids  the  specu- 
lum in  illuminating  the 
deep  recesses  of  the  vagina.  In  many  cases  the  uterine  dress- 
ing forceps,  grasping  a  small  piece  of  cotton,  may  be  substituted 
for  the  depressor.  The  smallest  speculum  which 
will  give  a  good  view  should  be  chosen  because 
the  small  instrument  does  not  stretch  the  hymen 
and  introitus  so  much  laterally,  and  thus  a  longer 
antero-posterior  slit  is  opened  in  which  the  smaller 
speculum  may  be  moved  about  freely.  It  is  a 
mistake  to  use  a  large  speculum  in  the  case  of  a 
tight  hymen  or  narrow  vagina,  because  with  it 
much  less  of  the  vagina  can  be  seen  and  the  patient 
is  caused  unnecessary  suffering.  The  opening  into 
the  vagina  should  be  oblong,  not  circular,  arid  ad- 
ditional room  is  obtained  only  by  carrying  the 
posterior  wall  of  the  vagina  backward. 

Looking  into  the  vagina  one  confirms  by  sight 
the  information  gained  by  touch  and  gains  addi- 
tional data.  The  ruga3  are  seen,  if  present,  con- 
ditions of  inflammation  are  noted,  also  the  caliber, 
length,  and  dilatability  of  the  canal  and  abnormal- 
ities of  shape  and  new  growths.  The  character 
and  amount  of  the  discharge  with  its  reaction, 
acid  or  alkaline;  the  cervix,  its  shape,  size,  loca- 
tion, whether  lacerated,  and  if  so,  the  situation 
and  extent  of  the  lacerations  as  determined  both 
by  sight  and  by  use  of  the  sound  and  tenacula, 
also  the  cervical  discharge,  its  character,  amount, 
and  reaction  are  all  noted.  Cover-glass  specimens 
cultures  from  the  discharge  may  be  made  if  necessary. 


FK:.  30. —Em- 
met Curette  For- 
ceps. 


and 


The  Emmet  Curette  Forceps. — This  is  one  of  the  most  valuable  of 
the  instruments  used  in  diagnosis.  With  it  one  removes  pieces  of 
tissue  from  the  uterine  cavity  for  examination  under  the  micro- 


PHYSICAL  EXAMINATION 


scope.  It  has  many  advantages  over  the,  curette,  especially  in 
cases  of  pedunculated  growths  which  often  are  not  caught  by  the 
curette.  This  instrument  can  not  damage  the  uterine  walls,  as  it 
does  nothing  more  than  pinch  the  bits  of  tissue  which  project 
above  the  surface  of  the  endometrium.  In  selecting  a  curette 
forceps  care  should  be  exercised  to  have  the  jaws 
ground  true  so  that  they  fit  accurately  together. 
Many  of  the  instruments  on  the  market  are  abso- 
lutely useless  because  the  jaws  have  rounded  edges 
which  do  not  fit  accurately  one  to  the  other  over 
their  entire  length.  In  consequence  the  tissue  which 
is  engaged  between  them  slips  out  and  is  not  pinched 
tightly  and  removed  as  it  should  be. 

Except  after  labor  or  abortion  the  cervical  canal 
must  be  dilated  to  a  moderate  degree  with  Hanks 
dilators  in  order  to  admit  the  closed  jaws  of  the  for- 
ceps. When  once  in  the  uterine  cavity  the  jaws  are 
separated  and  then  brought  together  again.  Then 
they  are  removed  from  the  uterus  and  the  contents 
washed  off  in  sterile  water.  The  process  is  repeated 
until  the  anterior  and  posterior  walls  of  the  cavity 
have  been  gone  over  thoroughly  and  systematically. 

The  Uterine  Curette. — One  curette  is  sufficient  for 
all  purposes  of  diagnosis.  This  is  a  sharp  loop  of 
medium  size,  the  shaft  of  the  instrument  being  made 
of  flexible  copper  so  that  it  may  be  made  to  conform 
to  a  bent  uterine  canal.  Also  with  a  flexible  shaft 
the  danger  of  doing  damage  by  too  forcible  curetting 
is  lessened.  Following  abortion  or  delivery  and  when 
there  is  flowing,  the  curette,  and  often  the  curette 
forceps  also,  may  be  introduced  through  the  cervical 
canal  without  dilatation,  except  under  such  conditions 
where  dilatation  is  necessary.  Curetting  should  only  rarely  be 
performed  without  an  anesthetic. 

Curetting. — htstnunentx  Needed. — Sound,  vulsellum  forceps,  Ede- 
bohls  speculum,  Hanks  dilators,  Wathen  dilator,  curette,  curette 
forceps,  two  uterine  applicators,  Bozeman's  uterine  douche  with 
irrigator  bag  and  tube. 

The  patient  is  anesthetized  with  ether,  cither  preceded  by  nitrous 


FIG.  31.— 
Uterine  Cu- 
rette. 


INSTRUMENTS  AND  THEIR  USE  91 

oxide  or  not,  according  to  the  preference  of  the  operator.  She 
is  placed  in  the  lithotomy  position  on  a  Kelly  pad  with  but- 
tocks at  the  edge  of  the  examining  table, 
the  legs  being  held  by  an  assistant  or  by 
portable  or  fixed  leg  holders.  The  biman- 
ual  touch  is  practiced.  The  vulva,  vagi- 
na, and  surrounding  regions  are  washed 
thoroughly  with  several  washings  of  soap 
and  hot  water,  then  with  alcohol,  and  final- 
ly with  sterile  water.  Observe  that  the 
bimanual  touch  is  made  before  the  wash- 
ing up.  This  is  because  the  tactile  sense  FlG  32  _Edebohls 
is  less  interfered  with  when  the  vagina  is  Vaginal  Speculum, 
lubricated  by  the  natural  secretions.  Af- 
ter irrigation  and  swabbing  with  alcohol,  and  especially  with  solu- 
tions of  corrosive  sublimate,  the  vagina  is  dry  and  clings  to  the 
finger,  sometimes  to  such  a  degree  that  the  sense  of  touch  is  very 
much  blunted.  Sterile  towels  are  placed  about  the 
field  of  operation  and  an  Edebohls  weighted  specu- 
lum, previously  sterilized  with  the  other  instru- 
ments, is  introduced  into  the  vagina.  The  anterior 
lip  of  the  cervix  is  seized  with  a  double  tenaculum 
forceps  and  the  sound  is  passed.  (For  facts  to  be 
learned  by  the  passing  of  the  sound  see  page  80.) 
The  cervix  is  dilated  by  passing  the  graduated 
Hanks  metal  dilators.  These  are  safer  than  the 
branched  steel  dilator,  which,  if  carelessly  used, 
makes  rents  in  the  uterine  walls,  more  especially 
in  the  neighborhood  of  the  internal  os.  These  rents 
are  not  always  recognized  by  the  operator. 

If  the  cervix  is  rigid  it  is  well  to  follow  the  Hanks 
dilators  with  a  steel  branched  dilator.  The  Wathen 
dilator  is  one  of  the  best  of  these.  After  it  has  been 
introduced  the  blades  are  to  be  separated  by  approx- 

Hanks  Uterine      .          .  J 

Dilator.  imatnig  the  handles  by  manual  pressure,   not    by 

turning  the  .set-screws,  as  is  so  often  done.  The 
reason  for  this  is  that  when  using  the  screw  the  operator  can 
not  judge  of  the  force  he  employs,  whereas,  by  manual  pres- 
sure, he  can  estimate  it  accurately.  When  sufficient  power 


PHYSICAL  EXAMINATION 


has  been  applied  the  screw  is  turned  until  the  handles  are  held 
in  place.     After  the  uterine  muscle  is  tired  the  handle's  are  brought 

a  little  nearer  together  and  the  screw 
takes  up  the  slack. — thus  relieving  the 
operator's  hands.  Fifteen  minutes  are 
necessary  for  dilatation,  more  if  the 
dilatation  is  to  be  excessive,  as  in  cases 
where  it  is  best  to  insert  the  finger  into 
the  uterine  cavity  for  purpose  of  ex- 
ploration. Dilatation  being  accom- 
plished, the  curette  is  introduced  and 
the  walls  of  the  uterine  cavity  are  gone 
over  systematically,  an- 
terior wall,  posterior  wall, 
lateral  sulci,  fundus,  and 
region  of  the  internal 
os.  The  curette  forceps 
always  supplements  the 
curette  and  many  are  the 
polypi  \vhich  have  escaped 
the  curette  that  are  seized 
by  the  curette  forceps. 
The  curetting  should  be 
stopped  when  the  curette 
grates  on  the  firmer  sub- 
mucous  tissue  of  the  uter- 
ine wall.  The  feeling  im- 
parted to  the  curette  is 
characteristic.  The  pieces 
of  tissue  obtained  are  col- 
lected from  the  vagina  on 
swabs  of  wet  sterile  gauze 
held  in  the  dressing  for- 
ceps and  transferred  at  once  to  a  ten-per-cent  formalin 
solution,  in  which  they  are  preserved  for  the  path- 
ologist. The  uterine  cavity  is  irrigated  freely  with 
hot  sterile  water  or  hot  salt  solution  and  swabbed 
dry  with  gauze  wound  around  a  uterine  applicator.  Bozeman's 
uterine  douche  is  as  good  as  any  for  purposes  of  irrigating  the 


Fm. 


34.— Wat  hen 
Dilator. 


Uterine 


FIG.  35.— 
B  o  z  e  m  a  n  - 
Fritsch  Uter- 
ine Irrigator. 


INSTRUMENTS  AND  THEIR  USE 


93 


uterine  cavity,  though  in  cases  of  long  and  rigid  cervix,  the 
Barrage  uterine  speculum  is  useful  both  for  irrigation  and  for 
swabbing  the  uterine  interior.  For  packing  the  uterine  cavity 
with  gauze,  a  procedure  sometimes  necessitated  in  obstinate 
hemorrhage,  this  latter  instrument  is  invalu- 
able, for  the  gauze  slips  easily  through  the 
metal  tube  of  the  speculum  into  the  uter- 
ine cavity  instead  of  clinging  to  the  tissues 
of  the  cervical  canal. 

The  vagina  is  now  protected  by  placing  a 
pledget  of  sterile  gauze  in  the  posterior  vagina 
under  the  cervix,  and  the  uterine  cavity 
is  swabbed  out  with  a  uterine  applicator 
wound  with  gauze  and  dipped  in  pure  car- 
bolic acid.  This  swabbing 

serves  a  triple  purpose: — it  an- 

tisepticizes  the  uterine  cavity, 

thus    providing     for     possible 

errors  in  technique;    it  mildly 

cauterizes  the  uterine  interior, 

thus  checking  hemorrhage;  and 

it  destroys  the  little  islands  of 

tissue  which  have  been  missed 

by  the  curette.     By  studying 

the  interior  of  uteri  which  have 

been  removed  by  hysterectomy 

— a  previous  curetting  without 

swabbing  having  been  done — it 

has  been  my  experience  to  find 

that   there  are  nearly    always 

present  at  least  one4  or  two  bits 

of  adventitious  tissue  left  behind  by  the  curette. 
The  Dant/ers  of  Curetting. — These  are:  (1)  per- 
foration of  the  uterus,  a  very  considerable  danger 
in  septic  conditions  and  after  labor;  (2)  hemorrhage,  especially 
after  labor  or  abortion  when  the  uterine  sinuses  are  large;  (3)  the 
removal  of  the  entire  endometrium  and  submucous  layer  prevent- 
ing regeneration  and  causing  the  formation  of  scar  tissue  and 
subsequent  sterility;  and  (4)  septic  infection  from  the  inocula- 


FIG.    36.  —  Burrage 
Uterine  Speculum. 


FIG.  37.— 
Uterine  Ap- 
plicator. 


94 


PHYSICAL  EXAMINATION 


tion  of  the  cndometrium  with  septic  matter  already  there  or  in- 
troduced from  without.  Perforation  is  avoided  by  using  the  great- 
est gentleness  in  curetting  septic  cases  and  in  using  the  curette 
forceps  or  the  finger  instead  of  the  curette  wherever  possible. 

If  hemorrhage  occurs,  the  uterine  cavity  is  to  be  irrigated  with 
very  hot  water  (120°  Y.\  and,  this  failing,  it  is  to  be  packed  with 
gauze.  For  this  purpose  a  Burrage  uterine  speculum  and  forked 

pusher  will  be  found 
most  useful.  The  re- 
moval of  the  entire 
endometrium  and  sub- 
mucous  layer  is  avoid- 
ed by  observing  the  di- 
rections already  given, 
and  the  production  of 
septic  infection  by  ob- 
serving strict  asepsis 
and  by  not  operating 
during  acute  attacks 
of  pelvic  inflamma- 
tion. 

Digital  Exploration  of 
the  Uterine  Cavity. — 
This  is  practiced  ordi- 
narily for  complete  in- 
vestigation in  cases  of 
doubt.  The  dilatation 
is  effected  by  means  of 
the  Hanks  dilators,  fol- 
lowed by  the  Wat  hen 
dilator.  The  Bossi  uterine  dilator  or  large  steel  rectal  dilators  are 
useful  for  the  extreme  stages  of  the  dilatation.  The  bare  finger 
should  be  employed  for  the  exploration  because  thus  the  full  ben- 
efit of  the  tactile  sense  is  to  be  obtained.  In  exceptional  cases, 
those  with  rigid  cervices  where  danger  of  rupture  of  the  tissue  is 
great,  a  valuable  method  of  exploring  the  uterine  cavity  is  that 
described  most  fully  in  Dr.  Howard  A.  Kelly's  "Operative  Gyne- 
cology,"  Second  Kdition,  Vol.  I.,  page  ~>96.  An  anterior  colpotomy 
is  performed,  the  transverse  incision  being  used.  After  the  vagina 


38.  — Transverse 
Cervix. 


Incision 

(Kelly.) 


INSTRUMENTS  AND  THEIR  USE 


95 


and  bladder  have  been  separated  from  the  uterus  by  blunt  dis- 
section, the  cervix  is  steadied  by  two  vulsella  and  the  anterior  lip 
of  the  cervix  is  divided  between  them  with  scissors  to  a  point 
beyond  the  internal  os.  The  digital  examination  of  the  uterine 
interior  completed,  the  divided  uterine  walls  are  brought  together 
with  sutures  and  the  vagina  is  then  replaced  and  sutured.  In  my 
experience,  a  certain  amount  of  preliminary  dilatation  of  the  cervix 
facilitates  this  opera- 
tion. (See  Figs.  38-41.) 

The  remaining  in- 
struments in  the  ex- 
aminer's kit,  namely, 
those  for  the  investi- 
gation of  the  urethra, 
bladder,  and  ureters, 
and  those  for  the  ex- 
amination of  the  rec- 
tum, will  be  described 
in  the  succeeding  chap- 
ters devoted  to  these 
subjects. 

Pel  vim  e  try. — The 
gynecologist  is  fre- 
quently consulted  by 
women  who  wish  to 
know  whether  they 
have  any  pelvic  de- 
formity that  would  be 
a  hindrance  to  their 
having  children,  also 
by  those  who  are  already  pregnant  with  the  same  query,  there- 
fore it  seems  best  to  describe  the  measurement  of  the  pelvis.  B. 
C.  Hirst  ("Diseases  of  Women,"  p.  419)  thinks  that  deformed 
pelves  occur  in  about  seven  per  cent  of  the  white  women  of  large 
American  cities,  but  that  they  are  comparatively  infrequent  among 
the  upper  classes  and  in  the  rural  agricultural  districts,  while 
frequent  among  negroes.  A  general  practitioner  in  a  city  can 
hardly  hope  to  avoid  seeing  cases  of  pelvic  deformity.  For  the 
many  forms  of  pelvic  deformities  the  reader  is  advised  to  consult  a 


39. — Incising    the    Anterior    Wall   of    the 
Cervix.      (Kelly.) 


96 


PHYSICAL  EXAMINATION 


modern  text-book  on  obstetrics.  The  commonest  forms  are  simple 
flat  pelvis,  generally  equally  contracted  pelvis  (justo-rninor),  and 
generally  contracted  flat  pelvis.  These  are  all  due  to  faulty  devel- 
opment of  the  skeleton.  The  other  rarer  forms  arc  caused  by 
disease  of  the  pelvic  bones  and  anomalies  in  the  sacro-iliac  and 
pubic  joints. 

To  practice  pelvimetry  successfully  one  must  have  a  reliable 
tape  measure  and  a  pelvimeter.     The  latter  is  a  large  pair  of 

calipers  with  a  scale  divided  into  cen- 
timeters and  inches.  The  measure- 
ments to  be  made  are  the  antero- 
posterior  diameter  of  the  superior 
strait,  the  capacity  of  the  pelvic  cav- 
ity, and  the  transverse  diameter  of  the 
pelvic  outlet.  In  exceptional  cases  of 
obliquely  contracted  pelvis  it  may  be 
necessary  to  measure  the  oblique  di- 
agonal diameters  of  the  pelvic  inlet. 
The  patient  must  be  prepared  as  for  a 
vaginal  examination  and  should  be  in- 
spected first  in  the  standing  position  to 
note  the  posture,  shape  of  the  back, 
and  inclination  of  the  pelvis. 

External  or  Baudelocque' s  Conjugate 
Diameter  (8  inches,  or  20.5  centi- 
meters).—On  inspecting  the  standing 
woman  from  behind,  one  sees  in  some 
cases,  not  in  all,  Michaelis'  rhomboid, 
a  lozenge  or  diamond-shaped  surface 
on  the  skin  at  the  base  of  the  spine. 
The  four  points  making  the  diamond 
are: — on  the  sides,  a  depression  at  each  upper  corner  of  the 
sacrum;  at  the  bottom,  the  notch  between  the  buttocks;  and 
at  the  top,  the  depression  over  the  spine  of  the  fifth  lumbar  ver- 
tebra. If  this  depression  can  not  be  seen,  the  spines  of  the 
vertebra1  are  felt  by  the  finger  from  above  downward  until  the 
last  one  is  reached.  The  tip  of  the  pelvimeter,  guided  into  place 
by  the  physician's  finger,  is  placed  in  the  depression  just  below 
the  last  spine.  The  other  point  of  the  pelvimeter  is  placed  on 


FIG.  40.— Uterine  Cavity  Laid 
Open.     (Kelly.) 


INSTRUMENTS  AND  THEIR  USE 


97 


the  anterior  upper  margin  of  the  symphysis  pubis,  exactly  in 
the  middle  line.  Firm  pressure  is  made  arid  the  reading  on  the 
scale  of  the  pelvimeter  is  taken.  The  true  conjugate  can  not  be 
estimated  accurately  from  the  external  conjugate  because  of  the 
uneven  thickness  of  the  pelvic 
bones  in  different  individuals, 
and  also  because  of  the  varying 
obliquity  of  the  pubic  bone.  An 
external  conjugate  of  6^  inches, 
16  centimeters,  or  under,  means 
surely  an  antero-posterior  con- 
tracted pelvis,  anything  over  8 
inches,  20.5  centimeters,  is  nor- 
mal or  large. 

The  oblique  conjugate  diameter 
(5J  inches,  or  12.8  centimeters), 
or  the  distance  from  the  prom- 
ontory of  the  sacrum  to  the 
under  margin  of  the  symphysis 
pubis,  may  be  measured  by  ex- 
amining the  woman  in  the  dorsal 
position.  Two  fingers  of  the  left 
hand  are  introduced  into  the  va- 
gina and  the  middle  of  the  prom- 
ontory of  the  sacrum  reached 
with  the  tip  of  the  middle  finger. 
Be  careful  not  to  mistake  the  last 
lumbar  for  the  first  sacral  ver- 
tebra and  be  gentle  and  not  too 
rapid  in  performing  this  ma- 
nipulation. AYith  the  tip  of  the 
forefinger  of  the  right  hand, 
mark  the  point  at  the  base  of 
the  thumb  of  the  left  hand 
touched  by  the  lower  edge  of  the  symphysis.  After  the  hand  has 
been  removed,  the  distance  between  the  tip  of  the  middle  ringer 
and  this  point  is  measured  by  the  tape  measure.  Subtract  from 
this  f  of  an  inch,  or  1.75  centimeters  (representing  the  thick- 
ness of  the  symphysis),  to  obtain  the  true  conjugate.  The 

7 


FIG.  41. — Exploring  Uterine   Cavity 
with  Finger.     (Kelly.) 


98 


PHYSICAL  EXAMINATION 


measurement  of  the,  normal  true  conjugate  is  4f  inches,  or  11 
centimeters. 

The  transverse  diameter  (of  inches,  or  13.5  centimeters). — This 
diameter  is  inferred  from  measurements  of  the  iliac  bones.  The 
distance  between  the  anterior  superior  spinous  processes  of  the 
ilia  in  well-formed  women  is  10J  inches,  or  26  centimeters;  the 
distance  between  the  crests  of  the  ilia  at  their  widest  points  is  11$ 

inches,  or  29  centimeters;  the  dis- 
tance between  the  trochanters  is 
12|  inches,  or  31  centimeters.  In 
making  these  measurements  the 
patient  is  in  the  dorsal  position, 
but  with  the  thighs  extended. 

The  Transverse  Diameter  of  the 
Outlet  (4f  inches,  or  11  centime- 
ters) . — This  is  the  distance  between 
the  tuberosities  of  the  ischia  and 
is  measured  with  the  patient  in 
the  lithotomy  position,  the  pelvi- 
meter  being  employed  as  in  the 
other  external  measurements. 

The  Capacity  of  the  Pelvic  Cav- 
ity.— This  is  an  estimate  formed 
by  vaginal  examination  with  two 
fingers  in  the  vagina.  When  the 

oblique  conjugate  is  being  measured  the  opportunity  should  be 
seized  to  palpate  the  interior  of  the  pelvis  and  form  an  idea  of  its 
capacity,  as  well  as  a  search  made  for  abnormalities  in  the  shape 
of  new  growths,  old  fractures,  caries,  or  necrosis. 

The  Oblique  Diagonal  Diameters  (84  to  9g-  inches,  or  22  to  23 
centimeters). — These  are  measured  by  the  pelvimeter  with  the 
patient  lying  first  on  one  side  and  then  on  the  other.  One  end  of 
the  pelvimeter  is  placed  on  the  posterior  superior  iliac  spine  on  one 
side  and  on  the  anterior  superior  iliac  spine  on  the  other.  The 
right  oblique  diagonal  is  generally  a  trifle  longer  than  the  left. 
The  posterior  superior  spinous  processes  are  often  marked  by 
distinct  dimples  on  the  woman's  back. 


FIG.  42. — The  Pelvimeter. 


CHAPTER  VIII 

THE  INVESTIGATION  OF  THE  URETHRA,  BLADDER,  AND 

URETERS 

Instruments  used,  p.  99. 

Anatomy,  p.  100.  The  urethra,  p.  100.  The  bladder,  p.  101.  Land- 
marks in  the  bladder,  p.  102.  The  ureters,  p.  104. 

The  examination,  p.  107.  Catheterization  of  the  bladder,  p.  108.  Search- 
ing the  urethra  and  the  bladder,  p.  108.  Direct  endoscopy  and  cystoscopy 
with  air  distended  urethra  and  bladder,  p.  110.  Catheterization  of  the 
ureters,  p.  115.  Indirect  cystoscopy  with  water  distended  bladder,  p.  117. 
Chromocystoscopy,  p.  119. 

IN  this  chapter  we  will  consider  only  direct  urethroscopy  and 
cystoscopy  by  means  of  a  simple  tube  (the  Kelly  cystoscope)  and 
reflected  light,  as  a  means  for  the  inspection  of  the  urethra  and 
bladder,  for  it  has  been  found  in  the  author's  experience,  to  meet 
satisfactorily  the  gynecologist's  requirements  for  diagnosis.  More- 
over, the  method  is  easily  learned  and  simpler  than  cystoscopy  with 
a  Nitze  cystoscope  or  instrument  of  that  class,  by  which  an  electric 
lamp  is  introduced  into  the  water-distended  bladder.  As  indirect, 
electric  cystoscopy  is  applicable  occasionally  where  the  air-dis- 
tended bladder  method  cannot  well  be  used, and  as  many  physicians 
prefer  it  as  a  method  of  diagnosis,  I  have  added  as  an  appendix  a 
description  of  the  steps  of  this  sort  of  cystoscopy  as  I  have  seen  it 
employed  in  competent  hands. 


INSTRUMENTS   USED 

Silver  female  catheter,  long. 

Kelly  meatus  calibrator. 

Kelly  steel  urethra!  sounds,  one  set. 

Kelly  cystoscopes,  Nos.  8,  10,  and  12. 

Kelly  ureteral  searcher. 

99 


100       THE  URETHRA,  BLADDER,  AND  URETERS 

Two  Kelly  ureteral  catheters. 
Rubber  bulb  and  tube  for  suction. 
Alligator  bladder  forceps. 
Uterine  applicator. 
Sims  speculum. 
Head  mirror. 

To  this  list  of  instruments  are  added: 

A  sterile  ten-per-cent  solution  of  cocaine  hydrochloratc  in  water. 
A  sterile  four-per-cent  solution  of  boric  acid. 
Absorbent  cotton. 

A  sterile  eight-ounce  bottle  with  stopper. 
Two  sterile  two-ounce  bottles  with  stoppers. 
A  two-quart  fountain  syringe,  and  a 
Collapsible  tube  of  lubrichondrin,  or  K-Y  jelly. 

« 

Not  every  woman  who  complains  of  urinary  symptoms  is  to  be 
subjected  to  a  cystoscopic  examination.  For  instance,  frequency 
of  micturition  associated  with  early  pregnancy,  although  not  pre- 
cisely normal,  generally  represents  increased  congestion  of  the 
upper  urethra  and  the  neck  of  the  bladder,  due  to  the  pregnant 
state,  and  is  to  be  disregarded,  unless  the  symptoms  are  so  severe 
that  they  undermine  the  health  by  interfering  with  rest  and  sleep. 
Only  when  urinary  symptoms  are  persistent  as  wrell  as  severe,  are 
the  urinary  organs  to  be  investigated. 

Before  proceeding  to  the  examination  let  us  review  the  salient 
features  of  the  anatomy  of  the  urethra,  bladder,  and  ureters. 


ANATOMY 

The  Urethra. — The  urethra  is  a  membranous  canal  varying 
from  an  inch  and  a  quarter  to  an  inch  and  a  half  in  length 
(3  to  3.o  centimeters)  extending  from  the  meat  us  urinarius  to 
the  neck  of  the  bladder.  It  lies  under  the  arch  of  the  pubes, 
its  lower  extremity  being  separated  from  the  pubic  bone  by 
about  four-tenths  of  an  inch  (1  centimeter).  It  is  parallel  with 
the  vagina  and  is  embedded  in  its  wall,  its  course  being  slightly 
curved,  the  concavity  directed  forward  and  upward.  Its  diame- 
ter when  undilated  is  about  a  quarter  of  an  inch  (6  millimeters). 


ANATOMY 


101 


The  meatus  urinarius  opens  into  the  vestibule  just  above  the  open- 
ing of  the  vagina. 

In  virgins  the  meatus  is  a  vertical  slit  about  a  fifth  of  an  inch 
long,  formed  by  two  little  lips  which  close  the  orifice  and  protect 
it  from  infection.     In  old   women  these  lips  are 
lacking.  Q 

The  wall  of  the  urethra  consisting  of  three 
coats,  muscular,  erectile,  and  mucous,  is  about  one- 
fifth  of  an  inch  thick  and  is  dilatable  to  a  consider- 
able degree,  the  meatus  being  the  most  resistant 
part.  It  is  not  safe,  however,  to  dilate  the  urethra 
beyond  twice  its  normal  diameter,  i.e.,  beyond  half 
an  inch  (12  millimeters),  because  of 
the  danger  of  permanent  inconti- 
nence of-  urine. 

When  the  urethra  is  not  distended 
the  mucous  coat  is  thrown  into 
longitudinal  folds,  one  of  which, 
placed  along  the  floor  of  the  canal, 
resembles  the  verumontanum  in  the 
male  urethra,  The  canal  is  lined 
with  stratified  epithelium,  which  be- 
comes transitional  near  the  bladder. 
In  the  floor  of  the  urethra  are 
two  little  tubular  glands,  half  an 
inch  long  and  about  a  thirty- 
second  of  an  inch  in  diameter, 
placed  length-wise,  with  their  ori- 
fices at  the  meatus,  just  within  or 
upon  the  labia  urethra.  These 
are  Skene's  glands.  It  is  thought 
that  the  function  of  these  glands 
is  to  secrete  a  lubricating  mucus  to  protect  the 
meatus  from  trauma  during  coitus. 

The     Bladder. — The    bladder,   a  musculo-mem- 
branous  sac  embedded  in  connective  tissue,  when 
quite  empty  and  contracted  is   cup-shaped,  and 
on  vertical  median  section  its  cavity,  with  the  adjacent  portion  of 
the  urethra,  presents  a  Y-shaped  cleft,  the  stem  of  the  Y  corre- 


14 


FIG.  43.— 
Silver  Female 
Catheter. 


FIG.  44.— Kel- 
ly Meatus  Cali- 
brator. 


102 


THE  URETHRA,   BLADDER,    AND  URETERS 


spending  to  the  urethra.  When  slightly  distended  the.  bladder 
has  a  rounded  form  and  is  still  contained  within  the  cavity  of 
the  pelvis  ;  when  greatly  distended  it  is  ovoid  in  shape,  rises 
into  the  abdominal  cavity,  and  may  reach  as  high  as  the 
umbilicus.  Its  capacity  is  about  a  pint. 

For  purposes  of  description  the  bladder  may 
be  divided  into  a  superior,  an  antero-inferior, 
and  two  lateral  surfaces,  also  a  base  or  fundus, 
and  a  summit  or  apex. 

The  superior,  or  abdominal  surface,  is  free 
toward  the  peritoneal  cavity  and  is  covered 
with  peritoneum;  the  antero-inferior  portion 
looks  toward  the  posterior  surface  of  the  sym- 
physis  pubis  and  is  uncovered  by  peritoneum; 
the  lateral  surfaces  are  covered  by  peritoneum 
except  in  their  lower  portions  where  they  come 
in  contact  with  the  broad  ligaments;  the  fundus 
or  base  of  the  bladder  is  directed  downward  and 
backward  and  is  partly  covered  by  peritoneum 
and  partly  uncovered.  It  is  connected  with  the 
anterior  aspect  of  the  cervix  and  with  the  an- 
terior wall  of  the  vagina  by  areolar  tissue,  the 
union  between  the  bladder  and  vagina  being 
closer  than  that  between  the  bladder  and  cer- 
vix. The  upper  portions,  of  the  bladder  are  more  movable 
than  the  lower  and  when  viewed  through  the  cystoscope  may 
be  seen  to  move  with  respiration. 

The  so-called  neck  of  the  bladder  is  the  point  of  beginning 
of  the  urethra,  but 
true  neck,  as   there 
tapering    part.        1 
tonic     contrao 
tion  of  tlu 

muscular 

/.,  •         VL_^-  teral   Searcher 

fibers   in 

the  bladder  wall  at  this  point  prevents  the 

escape  of  urine. 

The  bladder  is  composed  of  four  coats: 
FIG.  46.— Kelly  Evacuator.  serous,  muscular,  submucous,  and  mucous. 


FKJ.  45.—  The 
Kelly  Double- 
ended  Urethral 
Dilator. 


ANATOMY  103 

The  serous  coat  is  derived  from  the  peritoneum  and 
is  therefore  partial;  the  muscular  coat  is  made  up  of 
three  layers  of  unstriped  muscular  fibre,  two  of  them 
being  longitudinal,  and  one,  circular  in  direction ;  the 
submucous  coat  is  the  areolar  tissue  which  connects 
the  muscular  with  the  mucous  coat.  The  mucous  coat 
is  thin,  smooth,  and  of  a  pale  rose  color,  and  is  thrown 
into  folds  or  rugae  when  the  bladder  is  empty.  There 
are  no  true  glands  in  the  mucous  membrane. 

Landmarks  in  the  Bladder. — When  the  bladder  is 
distended  with  air  it  forms  a  hollow  sphere.  The  in- 
ternal orifice  of  the  urethra  or  neck  of  the  bladder  is 
a  definite  landmark  to  be  recognized  by  the  observer 
looking  through  the  cystoscope  as  the  first  portion 
of  mucous  membrane  which  rolls  into  the  lumen  of 
the  cystoscope  as  its  end  is  withdrawn  through  the 
urethra.  The  ureteral  orifices  are  two  minute  open- 
ings situated  in  small  elevations  of  the  mucous  mem- 
brane of  the  bladder  (mons  ureteris),  an  inch  apart, 
one  on  each  side  of  the  median  line  and  each  three- 


05 


quarters  of  an  inch  (2  centimeters)  from  the  internal 
orifice  of  the  urethra.  These  three  points  mark  out 
the  trigone  of  the  bladder. 

There  is  sometimes  seen  the  interureteric  liga- 
ment, a  distinct  fold  elevated  above  the  level  of 
the  surrounding  rnucosa  connecting  the  ureteral 
orifices. 

The  location  of  lesions  in  the  bladder  is  described 
by  means  of  these  landmarks  and  by  the  natural 
divisions  of  the  bladder  already  given. 

The  Ureters.  —  The  ureters  are  two  cylindrical  mem- 
branous tubes  lying  in  the  loose  connective  tissue 
behind  the  abdominal  and  pelvic  peritoneum,  about 
three-sixteenths  of  an  inch  (6  millimeters)  in  diameter 
and  twelve  inches  (30  centimeters)  long,  extending 
from  the  pelvis  of  the  kidneys  to  the  bladder.  The  FIG.  48.— 
length  of  the  ureters  depends  in  some  measure  on  the  Kelly  Ure- 


length  of  the  trunk.     A  patient  having  a  long  trunk  a 

will  have   correspondingly    long    ureters.      Different 


104       THE  URETHRA,  BLADDER,  AND  URETERS 

authorities  give  the  length  of  the  ureters  all  the  way  from  ten  to 
sixteen  inches  (25  to  40  centimeters).  The  left  ureter  is  a  little 
longer  than  the  right  because  of  the  higher  position  of  the  left 
kidney.  The  ureter  is  funnel-shaped  as  it  leaves  the  pelvis  of  the 
kidney  and  then  the  lumen  has  a  diameter  of  an  eighth  of  an 
inch  (2  millimeters),  until  the  ureter  reaches  its  termination  in 
the  bladder  wall,  where  there  is  a  narrowing,  which  becomes  a 
complete  closure  when  the  bladder  is  distended.  This  closure 


FIG.  49. — Kelly  Cystoscope  with  Obturator. 

is  effected  by  the  oblique  insertion  of  the  ureter  in  the  bladder 
wall,  the  mucosa  and  anterior  portion  of  the  bladder  wall  forming 
with  the  upper  side  of  the  ureter  a  wedge-shaped  valve,  the  apex 
of  the  wedge  being  at  the  ureteral  orifice. 

The  ureter  lies  on  the  psoas  muscle  throughout  its  abdominal 
course,  at  the  brim  of  the  pelvis  it  lies  on  the  common  iliac 
artery.  Within  the  pelvis  it  runs  downward  just  outside  the  in- 
ternal iliac  artery,  and  then,  turning  forward  and  crossing  under 
the  uterine  artery,  it  passes  half-way  between  the  pelvic  wall  and 


ANATOMY  105 

the  cervix,  at  a  distance  of  about  half  an 
inch  from  the  latter,  under  the  base  of  the  broad 
ligament  to  the  bladder.  The  ureter  is  com- 
posed of  three  coats,  fibrous,  muscular,  and  mu- 
cous. The  fibrous  coat  is  continuous  with  the 
capsule  of  the  kidney  above  and-  is  lost  in  the 
bladder  wall  below;  the  muscular  coat  of  the 
ureter  proper  is  made  up  of  three  layers:  exter- 
nal, internal  longitudinal, and  middle  circular;  the 
mucous  coat  is  smooth  and  has  a  few  longitudinal 
folds.  It  is  continuous  with  the  mucosa  of  the 
bladder  below  and  the  pelvis  of  the  kidney 
above,  and  is  composed  of  several  layers  of  cells. 

The  ureters  transmit  the  urine  from  the  kid- 
neys to  the  bladder  intermittently  by  means  of 
peristaltic  waves  traveling  the  length  of  the 
ureter.  Through  the  cystoscope  the  urine  may 
be  seen  to  issue  from  the  ureteral  orifices  in 
little  spurts  and  the  ureteral  orifices  may  be 
seen  to  expand  and  contract,  the  spurts  being 
more  forcible  and  more  frequent  with  greater 
activity  of  the  kidneys,  the  normal  rate  being 
all  the  way  from  one  spurt  every  ten  seconds 
to  a  spurt  every  sixty  seconds. 

Observations  have  been  recorded  which  tend  to 
prove  that  the  movements  of  the  orifice  are  less 
frequent  when  the  kidney  on  that  side  is  func- 
tionally inactive.  Infection 
travels  from  the  bladder  up 
the  ureter  only  when  the 
valve-like  arrangement  at 
the  orifice    in  the  bladder 
has     been    destroyed,     or 
when     infective     material 
has   been  introduced  into 
the  ureter,  as  on  a  ureteral 
Catheter    Or    bougie.  FlG>  SO.— AUigatoTBladder  Forceps. 


!()()  TIIK   URETHRA,    BLADDER.    AND   URETERS 


THE   EXAMINATION 

Suppose  a  woman  presents  herself  complaining  of  marked  pain 
or  difficulty  with  urination,  or  she  has  noticed  pus  or  blood  in  the 
urine.  The  examination  is  conducted  as  follows:  The  patient 
is  instructed  not  to  pass  her  urine,  if  she  is  able  to  hold  it.  She  is 
placed  on  the  table  in  the  dorsal  position  (see  page  33).  The 


Fir..  .")]. — The  Normal  BhuUer.  Laid  Open  from  the  Front.      (Kelly.) 

external  genitals  are  inspected  and  a  sharp  lookout  is  exercised  for 
evidences  of  gonorrhea,  for  eczematous  skin  lesions,  or  abnormali- 
ties of  the  meatus. 

Redness  about  the  meatus  and  the  orifices  of  the  glands  of 
Skene  and  Bartholin.  with  the  possibility  of  expressing  a  drop 
or  two  of  pus  from  the  urethra  by  stroking  its  course  through 


THE  EXAMINATION  107 

the  wall  of  the  vagina,  makes  gonorrhea  most  probable.  Gon- 
orrhea being  suspected,  no  instrument  should  be  passed  beyond 
the  bladder  neck  for  fear  of  carrying  infection  into  that  organ. 

Inspection  shows  whether  the  labia  urethra?,  which  normally 
close  the  meatus  in  virgins,  are  in  apposition  or  separated ;  shows 
the  presence  of  a  urethral  caruncle  or  prolapse  of  the  mucous 
membrane  of  the  urethra  or  a  tumor  in  the  urethra  projecting 
through  the  meatus.  Inspection  also  shows  eczema  of  the  vulva 
caused  by  the  urine  of  diabetes  mellitus. 

Palpation  by  the  left  forefinger  in  the  vagina  reveals  thickening 
of  the  urethra  and  tenderness  at  any  portion  of  its  course,  also  a 


FIG.  52. — Urine   Spurting  from  Ureteral  Orifice,  as  Seen  through  Cystoscope. 

(Knorr.) 

suburethral  abscess  or  tumor,  and  the  bimanual  touch  reveals 
thickening  of  the  bladder  walls,  a  stone  in  the  bladder,  points  of 
tenderness,  a  distended  bladder,  or  a  vesico- vaginal  fistula.  Per- 
cussion over  the  pubes  determines  an  area  of  dullness  corresponding 
to  a  distended  bladder.  The  bimanual  touch  may  reveal  tenderness 
of  the  pelvic  portion  of  the  ureter  or  thickening  of  the  ureter  in  this 
part  of  its  course1,  or  a  stone  in  the  ureter. 

To  reach  the  upper  portion  of  the  pelvic  portion  of  the  ureter  the 
recto-abdominal  bimanual  touch  is  best.  Thin  and  relaxed  ab- 
dominal walls  are  a  necessity  for  success  in  this  field  of  investiga- 
tion, although  a  thickened  ureter  may  be  palpated  in  the  lowest 
two  inches  of  its  course  by  a  digital  vaginal  examination,  and, 
exceptionally,  a  thickened  ureter  may  be  seen  as  a  ridge  in  the 


108  THE  URETHRA,   BLADDER,    AND  URETERS 

vaginal  mucous  membrane  on  speculum  examination  of  the  vagina. 
Palpation  having  furnished  what  information  it  will,  the  next  step 
is  the  passage  of  the  silver  catheter. 

Catheterization. — I  prefer  a  long  catheter  of  small  caliber,  because 
it  may  be  used  both  as  a  searcher  of  the  urethra  and  bladder  as 
we'll  as  a  catheter.  The  mcatus,  vestibule,  and  inner  surfaces  of 
the  nymplue  are  sponged  with  three  or  four  pledgets  of  cotton 
soaked  in  sterile  water  or  weak  creolin  solution,  each  pledget  being 
thrown  away  as  soon  as  it  has  been  used  once.  That  is,  a  piece  of 
cotton  is  never  dipped  a  second  time  in  the  water.  Normally  the 
urethra,  as  in  the  case  of  the  vagina,  except  just  inside  the  external 
opening,  is  free  from  bacteria.  Well  lubricated,  the  sterile  catheter 
is  passed  gently  into  the  bladder,  the  direction  of  the  urethra  being 
borne  in  mind,  at  first  backward  parallel  with  the  axis  of  the 
vagina  until  the  bladder  neck  is  reached,  and  then  forward.  Care 
should  be  taken  not  to  touch  the  outer  end  of  the  catheter  before 
the  urine  is  collected,  and  the  lubricating  should  be  done  directly 
from  the  collapsible  tube  without  the  intervention  of  the  physician's 
fingers. 

The  urine  from  the  bladder  is  collected  in  the  sterile  eight-ounce 
bottle  for  analysis,  note  being  made  of  the  character  of  the  urine 
as  it  flows  from  the  catheter,  whether  clear,  cloudy,  or  bloody. 
Blood  at  the  beginning  indicates  that  its  source  is  the  ureter  or  kid- 
ney. Also  whether  the  last  part  is  cloudy,  showing  residual  pus; 
and  the  force  of  the  stream,  increased  in  distended  bladder  and  in 
cases  of  pressure  on  the  bladder  by  tumors  or  straining,  decreased 
in  atonic  bladder.  Suprapubic  pressure  may  be  necessary  to 
empty  such  a  bladder. 

Searching  the  Urethra  and  Bladder. — After  the  urine  has  been 
withdrawn  the  catheter  is  used  as  a  searcher,  the  greatest  gentleness 
being  employed.  The  bladder  walls  are  gone  over  systematically 
and  points  of  tenderness  noted.  AVith  a  finger  in  the  vagina  and 
the  searcher  catheter  in  the  bladder  the  thickness  of  the  bladder 
wall  at  the  base  is  estimated;  a  stone,  foreign  body,  or  phosphatic 
deposits  are  detected  by  a  gritting  sensation  transmitted  to  the 
catheter,  or,  in  the  case  of  a  stone,  by  a  metallic  click;  sometimes 
a  tumor  is  diagnosed  in  this  way.  In  cases  of  cystitis  it  is  not  wise 
to  sound  the  bladder  at  the  same  time  that  a  cystoscopic  examina- 
tion is  to  be  made  because  the  slightest  trauma  will  cause  bleeding. 


SEARCHING  THE  URETHRA  AND  BLADDER  109 

The  discharge  of  blood  through  the  catheter  at  the  end  of  catheter- 
ization  is  a  diagnostic  sign  of  cystitis. 

If  there  is  suspicion  that  the  bladder  is  contracted,  its  capacity 
may  be  measured  by  injecting  with  the  fountain-syringe  tube 
attached  to  the  catheter,  warm,  sterile,  one-per-cent  boric-acid 
solution  until  the  patient  has  a  strong  desire  to  urinate.  Then 
disconnect  the  syringe  tube  and  collect  and  measure  the  water' 
issuing  from  the  catheter.  In  cases  of  cystitis  it  is  wise  to  irrigate 
the  bladder  with  boric-acid  solution  before  ending  the  examination. 
For  this  purpose  the  process  just  described  is  repeated  several  times. 
It  is  to  be  noted  that  the  catheter  has  not  been  removed  from  the 
bladder  since  it  was  introduced,  thus  a  minimum  of  trauma  is 
inflicted  on  the  urethra  and  vesical  neck. 

The  bladder  searching  being  finished,  the  catheter  is  withdrawn 
slowly;  clonic  spasm  of  the  bladder  walls  is  noted  in  some  cases, 
indicated  by  a  drumming  of  the  movable  upper  portion  of  the 
bladder  on  the  less  movable  base.  If  the  bladder  is  irritable  or  the 
muscular  fibres  hypertrophied,  the  catheter  is  seized  with  greater 
firmness  at  the  bladder  neck  as  it  is  withdrawn. 

When  the  end  of  the  catheter  reaches  the  urethra  one  notes: 
points  of  tenderness,  pouches  in  the  mucous  membrane  or  abnormal 
size  in  the  lumen,  also  stricture,  by  no  means  rare,  its  situation  and 
relative  size.  With  a  finger  in  the  vagina  and  the  end  of  the 
catheter  in  the  urethra  one  determines  the  thickness  of  the  walls  of 
the  urethra,  the  extent  of  any  pouching  of  the  mucous  membrane, 
due  to  rupture  of  the  walls  from  trauma  during  delivery,  and  also 
dislocation  of  the  urethra  downward.  This  is  a  common  deformity 
and  one  often  overlooked.  To  detect  it  the  investigator  observes 
whether  the  urethra  is  in  close  relation  with  the  under  surface  of 
the  arch  of  the  pubes  as  it  should  be  normally,  or  far  away  from  it, 
as  it  is  when  dislocated.  In  cases  of  prolapse  of  the  uterus  the 
urethra,  together  with  the  bladder,  is  commonly  dislocated  to  a 
variable  degree.  Suppose  the  upper  third  of  the  urethra  is  dis- 
located downward  with  the  bladder.  The  catheter  is  passed  into 
the  urethra  most  gently  until  it  meets  the  obstruction  of  the  down- 
ward bend  of  the  urethra.  The  point  of  the  catheter  is  noted  by 
palpation  by  a  finger  in  the  vagina  and  thus  the  situation  of  the 
beginning  of  the  dislocation  is  determined. 

In  the  case  of  procidentia,  if  the  bladder  is  dislocated  a  curved 


110  THE  URETHRA,   BLADDER,   AND  URETERS 

utorino  sound  is  to  be  substituted  for  the  catheter  and  the  situation 
of  its  point,  as  felt  by  the  finger,  marks  the  lower  limits  of  the 
bladder  in  the  prolapsed  mass. 

Having  gained  all  the  facts  possible  by  the  use  of  the  catheter, 
the  next  proceeding  is  inspection  of  the  urethra  and  bladder. 

Direct  Endoscopy  (Inspection  of  the  Urethra),  and  Direct  Cysto- 
scopy  (Inspection,  of  Die  Bladder}. — The  patient  is  in  the  dor- 
sal position.  The  bladder  has  been  emptied  of  urine.  The 
tip  of  the  meatus  calibrator  is  passed  into  the  urethra  and  the 
size  of  the  undilated  meatus  LS  read  on  the  scale  of  the  calibrator. 
Suppose  it  reads  6  millimeters.  A  No.  10  cystoscope  may 
be  used  and  the  meatus  must  be  dilated  a  little.  This  should  be 
done  by  gentle  pressure  on  the  conical  calibrator  and  twisting  it, 
care  being  taken  that  the  lubrication  is  ample.  If  the  tissues 
about  the  meatus  prove  to  be  rigid  it  is  wise  not  to  make  all  of  the 
dilatation  at  one  sitting,  for  the  patient's  confidence  will  be  lost  if 
she  is  hurt  too  much.  If  there  is  a  stricture  of  the  urethra  it  must 
be  dilated  with  the  double-ended  steel  dilators,  and  the  dilatation 
should  occupy  several  sittings.  The  meatus  being  stretched  to 
10  millimeters  without  laceration  or  excessive  pain  to  the  patient, 
the  next  step  is  the  cocainization  of  the  urethra.  Sometimes,  if 
the  meatus  is  sensitive,  it  will  be  found  best  to  use  the  cocaine 
before  dilating  the  meatus. 

To  cocainize  the  urethra  wet  the  terminal  two  inches  of  the  uterine 
applicator  and  wrap  it,  using  a  sterile  rubber  glove  to  handle  the 
cotton,  with  a  thin  layer  of  absorbent  cotton  so  that  the  diameter 
of  the  wrapped  applicator  is  about  three-sixteenths  of  an  inch 
(4  millimeters).  Soak  this  in  sterile  ten-pcr-cent  cocaine  solution 
gently  insert  the  applicator  into  the  urethra,  hold  the  cotton  at 
the  meatus  with  two  fingers  while  the  applicator  is  withdrawn  with 
the  other  hand,  leaving  the  cotton  in  the  urethra. 

It  is  well  not  to  pass  the  tip  of  the  applicator  beyond  the  neck 
of  the  bladder,  because  if  this  is  done  ardor  urime  is  likely  to  be 
evoked  and,  the  cotton  acting  as  a  wick,  urine  will  drip  from  the 
end  projecting  from  the  meatus,  thus  diluting  the  cocaine  and 
soiling  the  patient's  clothing  while  she  is  being  put  in  the  knee- 
chest  position  for  the  cysloscopy. 

A  knee-chest  position,  modified  from  that  described  on  page 
56,  is  the  one  commonly  employed  for  cystoscopic  examinations. 


DIRECT  CYSTOSCOPY 


111 


In  this  case  the  thighs  are  not  vertical  as  in  the  correct  knee- 
chest  position,  the  knees  being  nearer  the  chest.  In  very  stout 
patients  and  in  certain  operative  cases  the  raised  pelvis  position 
(page  58)  is  employed.  By  the  time  all  the  instruments  are 
ready,  the  room  is  darkened,  and  the  patient  is  well  settled  in  the 
correct  knee-chest  position  (four  or  five  minutes),  the  cocaine 
should  have  produced  sufficient  anesthesia  of  the  urethra  to  permit 
us  to  proceed  with  the  cystoscopy. 

Artificial  light  is  necessary  for  cystoscopy.  An  electric  light, 
gas  light,  or  a  kerosene  lamp  is  to  be  chosen  in  the  order  named. 
The  ordinary  sixteen-candle-power  electric  lamp  is  sufficient,  a 


FIG.  53. — Modified  Knee-chest  Position  Used  in  Cystoscopy. 
Buttocks  in  the  Modified  Position. 


B.  Is  position  of 


thirty-two-candle-power  lamp  with  a  tin  reflector  is  better.  An 
argand  burner  makes  the  best  gas  light,  but  a  Welsbach  light  is 
good.  A  kerosene  lamp  must  have  a  circular  burner  so  as  to  give 
a  large  flame.  Any  lamp  should  have  the  shortest  possible  stand  so 
that  the  source  of  light  may  be  as  near  to  the  patient's  sacrum  as 
possible,  in  order  that  the  angle  formed  at  the  mirror  on  the  opera- 
tor's forehead  between  the  rays  from  the  source  of  light  and  the 
reflected  rays  going  into  the  bladder  may  be  as  acute  as  possible. 
It  should  be  remembered  that  the  electric  light,  if  held  near  the 
uncovered  skin  for  any  length  of  time,  will  cause  a  serious  burn. 
If  the  patient  is  anesthetized  this  is  a  very  important  fact  to  bear 
in  mind. 


112 


THE  URETHRA,  BLADDER,  AND  URETERS 


Light  reflected  by  a  head  mirror  from  an  ample  source  is  far 
better  as  an  illuminant  of  the  bladder  than  light  from  a  small 


FIG.  54. — Bladder,  Vagina,  and  Rectum  Ballooned  by  Air  Admitted  with  Pa- 
tient in  Knee-chest  Position.     (Kelly.) 

electric  headlight,  because  it  is  difficult  to  keep  the  field  illuminated 
with  the  small  light,  every  motion  of  the  head  deflecting  the  rays. 


DIRECT  CYSTOSCOPY 


113 


Any  form  of  illumination  introduced  into  the  bladder  obstructs 
the  view,  the  wires  for  the  lamp  cutting  off  a  part  of  the  lumen  of 
the  urethra,  besides  the  risk  of  burning  the  bladder  by  the  heat 
generated  by  the  lamp. 

All  being  in  readiness,  the  pledget  of  cocaine-soaked  cotton  is 
removed  from  the  urethra  and  a  well-lubricated  No.  10  cystoscope 
with  its  obturator  in  place  is  passed  into  the  urethra  and  bladder. 
If  air  docs  not  enter  the  vagina  it  is  well  to  open  the  introitus 


FIG.  55. — Suction  Apparatus  in  Use  for  Removing  Urine  from  Bladder.     (Kelly.) 

vaginrc  with  one  finger.  If  the  bladder  does  not  balloon  at  once, 
the  silver  catheter,  previously  cleaned  and  lubricated,  is  passed 
through  the  sphincter  ani,  thus  letting  air  into  the  rectum,  and 
permitting  the  trigone  of  the  bladder  to  come  more  into  view 
through  the  cystoscope. 

The  operator  sits  on  a  high  stool  and  looks  through  the  cysto- 
scope, which  should  be  practically  horizontal  if  the  patient  is  in  the 
proper  position. 
8 


Hi       THE  URETHRA,  BLADDER,  AND  URETERS 

If  urine  lias  collected  in  the  superior  portion  of  the  bladder,  or 
if  it  collects  during  the  examination,  it  is  to  be  removed  by  the 
bent  tube  introduced  through  the  cystoscope,  suction  being  applied 
by  means  of  the  bulb  and  rubber  tube  attached  to  the  tube  in  the 
bladder.  The  greatest  care  should  be  exercised  to  have  the  bulb 
and  tubes  sterile,  so  that  infection  may  not  be  introduced,  and  to 
this  end  the  bulb  should  be  squeezed  and  held  collapsed  while  the 
end  of  the  tube  is  rinsed  in  sterile  water  before  it  is  introduced. 
A  modified  chemical-laboratory  wash- bottle  may  be  used  for  re- 
moving the  urine,  as  shown  in  figure  55. 

In  cystoscopy  with  the  patient  in  the  elevated-pelvis  position 
the  collection  of  urine  at  the  fundus  of  the  bladder  is  much  more 
troublesome  than  it  is  when  the  patient  is  in  the  knee-chest  position, 
for  in  the  latter  position  the  urine  falls  into  the  capacious  superior 
part  of  the  bladder  behind  the  pubes. 

The  different  landmarks  of  the  bladder  are  sought  for,  the 
ureteral  orifices  inspected.  Bits  of  tissue  may  be  removed  from 
ulcerated  areas  or  new  growths  with  the  alligator  forceps;  cultures 
taken,  or  the  ureters  catheterized.  Of  the  last,  more  shortly. 

A  culture  is  taken  by  bending  the  handle  of  a  sterile  cotton- 
tipped  uterine  applicator  so  that  the  applicator  will  pass  through 
the  cystoscope  without  obstructing  the  view.  After  the  desired 
area  in  the  bladder  has  been  swabbed  with  the  cotton,  the  latter 
is  drawn  over  the  surface  of  the  slant  agar  tube,  hydrocele  agar 
being  used  when  gonococcus  infection  is  suspected. 

To  find  the  ureteral  orifices  first  determine  the  situation  of  the 
internal  opening  of  the  urethra.  This  is  done  by  noting  the  point 
at  which  the  urethra  1  mucous  membrane  begins  to  roll  into  the 
lumen  of  the  speculum.  The  trigone,  which  is  more  injected  than 
the  rest  of  the  bladder,  is  the  space  between  the  two  ureteral 
orifices  and  the  opening  of  the  urethra.  It  is  small;  therefore,  the 
ureteral  orifice  is  near  at  hand.  If  a  V  is  marked  on  the  external 
upper  part  of  the  cylinder  of  the  cystoscope,  with  its  point  toward 
the  bladder  end  and  the  side's  of  the  V  separated  by  an  angle  of 
thirty  degrees,  the  ureteral  orifice  on  one  side  may  be  found  by 
bringing  an  arm  of  the  V  parallel  with  the  axis  of  the  urethra,  when 
the  cystoscope  will  point  toward  the  ureteral  orifice  on  the  same 
side.  The  ureteral  opening  is  a  little  slit  situated  on  the  mons 
ureteris,  a  slight  eminence. 


OATHETERIZATION  OF  THE  URETERS  115 

Inspection  of  the  urethra,  endoscopy,  is  practised  as  the  cysto- 
scope  is  withdrawn.  The  neck  of  the  bladder  is  recognized  as  the 
first  part  of  the  rolling-in  rim  of  mucous  membrane  coming  into  the 
lumen  of  the  cystoscope  as  the  latter  is  being  withdrawn.  Then  in 
succession  follow  the  different  portions  of  the  urethra,  the  meatus 
being  last.  After  the  patient  has  been  restored  to  the  dorsal 
position  following  cystoscopy  in  the  knee-chest  position,  it  is 
essential  to  pass  the  silver  catheter  into  the  bladder  to  let  out  the 
air  which  has  accumulated.  If  the  physician  remembers  to  do 
this  the  patient  will  be  spared  the  ardor  urinse  and  the  discomfort 
which  attend  a  distended  bladder.  Occasionally  the  endoscope 
of  Skene  or  the  urethral  bivalve  speculum  recommended  by  him 
are  of  great  service  in  viewing  the  interior  of  the  urethra,  especially 
in  investigating  new  growths.  These  instruments  have  not  been 
included  in  the  list  of  instruments  necessary  for  the  investigation 
of  the  urethra,  because  the  cystoscope  generally  answers  every 
purpose  of  diagnosis,  and  simplicity  of  technique  is  aimed  at  in 
this  book. 

Catheterization  of  the  Ureters. — If  the  bladder  is  the  seat  of 
infective  inflammation  the  physician  should  debate  seriously  the 
advisability  of  catheterizing  the  ureters,  more  especially  if  he  has 
reason  to  believe  that  the  ureters  are  not  infected.  If  it  is  a 
question  of  unilateral  gonococcus  or  tuberculous  infection  of  kidney 
and  ureter  with  enlarged  kidney  and  thickened  ureter,  the  diseased 
ureter  should  be  catheterized,  the  healthy  ureter  should  not  be 
catheterized,  because  of  the  great  danger  of  introducing  septic 
matter  into  a  sound  ureter,  the  problem  being  similar  to  that  of 
passing  the  catheter  through  the  neck  of  the  bladder  in  cases  of 
gonorrhea  of  the  urethra,  or  of  introducing  instruments  beyond  the 
internal  os  uteri  in  infections  of  the  vagina  and  cervical  canal. 
Nature  has  set  up  well-defined  barriers  against  infection,  and  the 
physician  should  be  assured  of  good  results  to  follow  before  breaking 
them  down. 

The  ureteral  orifices  are  found  by  depressing  the  handle  of  the 
cystoscope  and  carrying  it  to  one  side  while  the  tip  is  raised  toward 
the  patient's  sacrum.  The  dimensions  of  the  trigone  are  borne  in 
mind  and  the  orifice  shows  in  the  proper  place  as  a  minute  opening 
from  which  a  drop  of  urine  spurts  every  few  moments.  The 
rapidity  of  the  flow  of  urine  is  dependent  on  the  activity  of  the 


116  THE  URETHRA,   BLADDER,   AND  URETERS 

kidney,  on  the  amount  of  fluids  the  patient  has  recently  taken, 
and  on  the  state  of  the  nervous  system.  Sometimes  it  is  advisable 
to  regulate  these  factors  before  proceeding  with  a  cystoscopy.  Both 
orifices  should  be  found  before  a  catheter  is  passed,  because  in 
some  cases  the  orifice  may  be  displaced  by  uterine  malpositions,  by 
pelvic  inflammation,  or  by  other  abnormalities  of  the  pelvic  organs. 

The  u  ret  end  orifice  being  found,  the  urcteral  searcher  is  passed 
into  it  to  make  sure  that  it  is  the  ureter  and  not  a  pocket  in  the 
mucous  membrane.  Then  the  catheter  is  passed  and  the  cystoscope 
is  withdrawn  over  it.  The  cystoscope  with  its  obturator  in  place 
is  reintroduccd  beside  the  catheter  and  the  opposite  ureteral  orifice 
is  found  and  catheterized  in  similar  fashion. 

Now  the  patient  is  gradually  lowered  into  the  dorsal  position, 
the  physician  guarding  the  ends  of  the  catheters  as  she  moves. 


FIG.  56. — Nitzc's  Model  of  Ureter  Cystoscope  for  Catheterizing  Both  Ureters. 

The  sterile  t\vo-ouncc  bottles  collect  the  urine  from  each  ureter, 
the  amount  of  urine  and  the  time  of  flow  being  noted  on  each  bottle 
as  well  as  the  ureter  from  which  the  urine  came.  Great  care  is  to 
be  taken  to  mark  the  bottles  correctly,  and  to  this  end  it  is  best 
to  stick  a  gummed  label  on  each  bottle  before  the  catheterization, 
and  to  mark  the  bottles  at  once  after  they  are  used. 

In  exceptional  cases  something  may  be  learned  as  to  stone  in 
the  ureter  or  stricture  of  the  ureter  by  passing  ureteral  bougies. 
Wax-tipped  bougies  have  been  used  with  success  in  diagnosticating 
stone  in  the  kidney,  but  much  skill,  gained  by  long  experience  in 
this  field,  is  necessary  to  produce  results. 

Catheterization  of  the  ureters  with  the  patient  in  the  elevated- 
pelvis  position,  a  more  convenient  position  when  an  anesthetic 
is  used,  is  conducted  much  as  in  the  knee-chest  position.  The 
light  is  held  close  to  the  patient's  pubes  and  the  operator  stands 
looking  downward,  through  the  cystoscope  to  the  trigone.  When 


INDIRECT  CYSTOSCOPY 


117 


the  catheters  are   in    place   the  patient's   pelvis   is   lowered  to 
the  table. 

It  should  be  remembered  that  the  cystoscopic  appearances  and 
the  situation  of  the  ureteral  orifices  are  altered 
by  malpositions  and  tumors  of  the  uterus  and 
by  other  pelvic  tumors.  For  instance,  in  pro- 
lapse folds  appear  in  the  bladder  mucosa  after 
reposition  of  the  uterus  and  the  cystocele. 

Indirect  Cystoscopy  with  Water-Distended 
Bladder. — The  instruments  necessary  are: — a 
Nitze  cystoscope  with  wires  and  electric-light 
connection,  a  current  controller  and  source  of 
electricity,  such  as  the  street  current  or  a 
storage  battery,  irrigating  bag  and  one-per- 
cent boric-acid  solution,  urethral  calibrator, 
urethral  catheter,  uterine  applicator,  absorb- 
ent cotton,  and  cocaine.  The  bladder  should 
have  a  capacity  of  at  least  five  ounces  and 
the  fluid  should  be  clear;  if  it  is  not,  an  irrigat- 
ing cystoscope  must  be  employed.  The  pa- 
tient is  in  the  dorsal  position ;  the  meatus  urin- 
arius  is  dilated  with  the  urethral  calibrator 
(cocaine  being  used  if  necessary  as  described 
in  direct  cystoscopy,  page  110)  until  it  will 
admit  a  No.  25  French  sound,  the  usual  diameter  of  most  cysto- 
scopes.  If  there  is  a  stricture  of  the  urethra  it  must  be  dilated. 
No  bleeding  should  accompany  the  introduction  of  the  cystoscope, 
because  it  will  spoil  the  view  in  the  bladder.  Before  introducing 
the  cystoscope  fill  the  bladder  with  boric-acid  solution  and  allow 
it  to  run  out  until  the  water  is  clear,  then  from  five  to  seven 
ounces  are  injected  and  the  catheter  withdrawn.  The  cystoscope 
is  connected  with  the  source  of  light  and  the  lamp  tested.  Then 
the  current  is  turned  off  and  the  instrument  is  smeared  with 
lubrichondrin  and  introduced,  care  being  taken  to  depress  the 
handle  as  the  curve  passes  the  neck  of  the  bladder. 

The  following  are  the  appearances  of  the  bladder  as  seen  through 
the  cystoscope  according  to  Casper  ("A  Text-Book  of  Genito- 
Urinary  Diseases  ").  The  normal  mucous  membrane  of  the  bladder 
varies  from  light  yellow  to  pink,  being  redder  at  the  base  than  in 


FIG.  57.  —  Current 
Controller  for  Use  with 
Electric  Cystoscope. 


US       THE  URETHRA.  BLADDER,  AND  URETERS 

other  parts.  In  the  course  of  a  prolonged  examination  urine  is 
poured  out  into  the  bladder  by  the  ureters  and  the  color  of  the 
nuicosa  becomes  redder  because  of  the  yellowness  of  the  medium 
through  which  it  is  seen,  also  if  the  brightness  of  the  light  dimin- 
ishes the  color  becomes  redder,  therefore  the  light  should  be  bright 

and  white.  The  delicate  ramifying 
blood-vessels,  especially  well  marked 
at  the  fundus,  are  similar  to  the 
vessels  seen  with  the  ophthalmoscope 
at  the  fundus  of  the  eye.  Bundles  of 
muscle  fibers,  parts  of  the  detrusor 
vesica?,  make  little  ridges  in  the  blad- 
der walls,  especially  in  the  superior 
and  lateral  portions.  Exaggerations 

FIG.  58. — Bladder  Phantom  for  * 

Practising  Cystoseopy.  of  these  ridges  become  the  "trabec- 

ula?"  in   the  cases  of  hypertrophy  of 

these  muscles  when  increased  work  has  been  thrown  upon 
them,  as  in  stricture  of  the  urethra.  Between  the  trabecula? 
may  be  diverticula,  which  look  like  deep  excavations  in  the  bladder 
wall.  A  shadow  will  cover  a  part  of  the  circular  field  of  vision  if 
the  cystoscope  is  withdrawn  from  the  middle  of  the  bladder.  This 
is  due  to  the  fact  that  a  part  of  the  prism  in  the  cystoscope  is 
covered  by  the  sphincter  vesico?  muscle.  Carrying  the  beak  of 
the  instrument  downward  brings  the  base  of  the  bladder  into  view, 
and  pushing  it  a  little  backward  and  to  one  side  brings  the  opposite 
ureteral  elevation  into  the  field.  If  the  ureteral  eminence  is 
watched  for  a  little  time  it  will  be  seen  to  swell  up  suddenly,  make 
a  convulsive  movement,  and  at  the  same  time  an  eddy  will  be 
observed  in  the  bladder  fluid.  This  is  the  periodic  discharge  of 
urine.  If  the  urine  is  discolored  the  bladder  fluid  will  have  to  be 
renewed  either  by  irrigation  through  a  catheter  or  an  irrigating 
cystoscope.  Often  the  urine  from  one  ureter  will  be  clear  and  from 
the  other  cloudy. 

This  form  of  cystoscopy,  like  the  direct  form,  should  not  be  used 
in  the  presence  of  acute  inflammation  of  the  bladder  and  it  can 
not  be  employed  in  the  case  of  a  contracted  bladder.  In  chronic 
catarrhal  cystitis  the  mucous  membrane  appears  to  be  puffy, 
velvety,  and  red,  and  is  coated  with  secretion.  The  vascular 
network  is  no  longer  visible,  the  surface  of  the  bladder  looking 


CHROMOCYSTOSCOPY 


119 


cloudy  and  dull.  Scales  and  flakes  of  secretion  are  found  floating 
free  in  the  fluid  or  on  the  bladder  wall.  Tuberculous  cystitis 
shows  nodules  surrounded  by  a  red  border  situated  mostly  on  the 
floor  of  the  bladder,  and  in  advanced  cases  distinct  ulcers  are 
visible.  Tumors  of  the  bladder  give  especially  good  pictures  with 
this  form  of  cystoscope  and  so  do  vesical  calculi.  Foreign  bodies 
can  be  distinguished  and  their  size  and  shape  determined,  and  a 
ureteral  catheter,  introduced  into  a  ureter,  may  be  seen  disappear- 
ing through  the  ureteral  orifice  and  throwing  a  shadow  below  it  on 
the  base  of  the  bladder. 

To  those  who  are  interested  in  this  form  of  cystoscopy  the 
following  books  are  recommended :  "  Die  Cystoskopie  beim  Weibe," 
Dr.  Richard  Knorr;  "Handbuch  der  Cystoskopie,"  Dr.  Leopold 


FIG.  59. — Luys  Urine  Separator.  It  Divides  the  Bladder  into  Halves  by 
a  Removable  Diaphragm  and  the  Urine  from  Each  Half  is  Collected  by  a 
Separate  Tube. 

Casper;  "Handatlas  der  Cystoskopie,"  Dr.  Otto  Kneise;  "A.  Hand- 
book of  Clinical  Cystoscopy,"  K.  Hurry  Fen  wick. 

Chromocystoscopy. — Chromocystoscopy  is  a  method  of  investigat- 
ing the  functional  capacity  of  each  kidney  that  has  been  used 
abroad  for  the  past  six  years  with  success.  It  consists  of  cysto- 
scopy with  water-filled  bladder.  Fifteen  minims  of  a  five-per-cent 
aqueous  solution  of  methylene  blue  are  injected  into  the  buttock. 
In  five  minutes,  more  or  less  in  individual  cases,  the  urine  is  rendered 
blue  and  can  be  seen  through  the  cystoscope  spurting  from  the 
mouths  of  the  ureters.  The  urine  from  the  two  ureters  is  com- 
pared as  regards  the  following  points: — The  interval  before  its 
appearance,  the  intensity  of  the  color,  the  number  of  jets  to  the 
minute,  and  the  force  of  the  jet.  If  one  ureter  eliminates  dark 
blue  urine  while  there1  is  no  trace  of  stain  in  the  urine  from  the  other 


120  THE  URETHRA,    BLADDER,   AND  URETERS 

kidney,  there  may  be  obstruction  by  a  stone  in  the  ureter  giving 
colorless  urine,  or  compression  of  this  ureter  so  that  the  passage  of 
the  urine  is  delayed,  or  such  extensive  destruction  of  the  kidney 
tissue  on  this  side  that  the  stain  has  not  been  excreted.  The 
method  is  said  to  obviate  the  necessity  for  ureteral  catheterization 
in  many  cases  and  to  give  a  reliable  indication  of  the  functional 
capacity  of  each  kidney,  besides  affording  a  means  of  finding  an 
otherwise  hidden  ureteral  orifice. 


CHAPTER  IX 

THE  INVESTIGATION  OF  THE  RECTUM 

Inspection  of  the  anus,  p.  121.  Anatomy  of  the  rectum,  p.  121.  Digital 
examination,  p.  123.  Proctoscopy,  p.  124.  Stretching  the  sphincter  and 
speculum  examination  of  the  rectum  with  an  anesthetic,  p.  126. 

THE  frequent  association  of  rectal  and  gynecological  affections 
makes  the  diagnosis  of  the  former  important,  also  symptoms  in 
gynecological  disease  are  so  often  referred  to  the  rectum  that  it 
becomes  most  necessary  to  eliminate  rectal  disease. 

Of  course  the  rectum  should  be  empty  before  an  examination 
is  made,  an  enema  being  given  if  there  is  any  doubt  on  this  point, 
and  it  should  be  given  always  in  cases  where  the  rectum  is  to  be 
investigated  with  the  proctoscope.  In  those  cases  in  which  there 
is  protrusion  of  the  bowel  only  at  stool,  the  patient  should  go  to 
the  closet  before  the  examination. 

Inspection  of  the  Anus. — The  best  position  for  both  visual  and 
digital  examination  is  the  Sims  position.  Inspection  of  the  anus 
may  show  external  hemorrhoids,  and  internal  hemorrhoids  after 
the  patient  has  just  been  to  the  closet,  external  fistulse,  ulcerations, 
pin  worms,  abscess,  fissure,  and  skin  diseases,  such  as  eczema  and 
venereal  warts.  If  the  buttocks  are  separated  by  the  hands  and 
the  patient  bears  down,  a  fissure  may  be  brought  into  view. 

Some  points  in  the  diagnosis  have  been  obtained  already  from  tKe 
vaginal  examination.  Tumors  can  be  ruled  out  by  the  vaginal 
touch.  The  sphincter  ani  is  now  everted  by  a  finger  in  the  vagina 
pressing  the  rectal  wall  out  through  the  anus,  thus  affording  an 
opportunity  for  study  and  a  search  for  hemorrhoids,  polypi,  ulcera- 
tions, fissures,  or  fistula?.  This  procedure  can  not,  however,  be 
executed  in  virgins  with  unstretched  perinea,  a  reasonable  amount 
of  injury  or  elasticity  of  the  perineum  being  a  necessity. 

Before  taking  up  the  digital  examination  let  us  review  a  few  points 
in  the  anatomy  and  physiology  of  the  rectum. 

Anatomy  of  the  Rectum. — The  rectum  is  about  eight  inches  long, 
merging  above  into  the  sigmoid  flexure  of  the  descending  colon  at 

121 


122  THE   INVESTIGATION  OF  THE  RECTUM 

the  loft  sacro-iliac  articulation,  there  being  no  distinct  point  of  sepa- 
ration between  the  two.  The  upper  portion,  four  inches  long,  is 
almost  completely  surrounded  by  peritoneum.  The  peritoneum 
is  reflected  from  the  anterior  surface  of  the  middle  portion  or 
ampulla,  which  is  three  inches  long,  at  a  point  about  two 
and  a  quarter  inches  from  the  anus  to  pass  on  to  the  posterior 
wall  of  the  vagina.  As  the  anterior  and  posterior  walls  of  this 
part  of  the  rectum  are  in  apposition  when  it  is  not  distended 
by  feces  or  gases,  it  appears  in  sections  as  a  transverse  slit. 
The  third  portion,  or  anal  canal,  an  inch  long,  is  the  part 
surrounded  by  the  internal  sphincter  above  and  external 
sphincter  below,  and  supported  by  the  levatores  ani  muscles. 
When  empty  this  part  is  seen  in  a  vertical  median  section  as  a 
longitudinal  slit.  It  is  to  be  borne  in  mind  that  the  long  axis  of 
the  canal  of  the  anus  is  nearly  horizontal  when  the  patient  is  in  the 
erect  posture  and  is  at  approximately  a  right  angle  to  the  long  axis 
of  the  two  upper  portions  of  the  rectum, — therefore  the  anus  dis- 
charges the  fluid  fecal  contents  not  downward  in  the  axis  of  the 
body,  but  backward.  The  soiled  state  of  the  rear  boards  of  a  coun- 
try privy  bears  testimony  to  this  fact  in  anatomy.  When  solid 
fecal  masses  are  passed  the  anal  canal  is  taken  up  much  as  the  cervix 
uteri  is  taken  up  during  labor,  and  the  feces  are  extruded  down- 
ward. This  obliquity  of  the  anal  canal  to  the  main  lumen  of  the 
rectum  lessens  the  direct  strain  on  the  sphincter  made  by  accu- 
mulations of  fecal  matter  and  gases. 

The  rectum  is  composed  of  four  coats, — serous,  muscular,  areolar, 
and  mucous.  It  is  similar  in  structure  to  the  rest  of  the  large  in- 
testine, except  that  the  semilunar  folds  of  the  mucous  membrane 
to  be  found  higher  up  in  the  bowel  are  here  strongly  developed,  so 
that  they  form  shelves  projecting  into  the  lumen  of  the  gut.  These 
shelves  or  valves  (valves  of  Houston)  are  generally  three  in  number, 
two  high  up,  are  on  the  sides  of  the  rectum,  a  third  and  the  largest, 
is  in  front  opposite  the  base  of  the  bladder.  AVhcn  a  fourth  is 
present  it  is  in  the  ampulla  on  the  posterior  wall  about  an  inch 
above  the  anus.  These  valves  are  disposed  alternately.  When 
the  rectum  is  empty  they  overlay)  each  other  so  that  it  is  difficult  to 
pass  a  bougie  or  other  foreign  body  by  them.  Their  function  is 
probably  to  support  the  weight  of  fecal  matter  and  prevent  it  from 
impinging  on  the  anus  where  its  presence  is  sure  to  excite  a  desire 


DIGITAL  EXAMINATION  123 

for  defecation.  Just  above  the  internal  sphincter  the  mucous 
membrane  is  thrown  into  three  or  four  longitudinal  folds  on  each 
side.  These  are  known  as  the  columns  of  Morgagni.  Between 
them  are  little  pockets,  or  valves. 

The  vessels  of  the  rectum  lie  in  the  loose  areolar  tissue  between 
the  muscular  and  mucous  coats,  and,  receiving  no  support  from  the 
muscles,  varicosity  is  favored.  Moreover,  the  veins  pierce  the 
muscular  coat,  run  superficially  in  a  longitudinal  direction,  and 
are  apt  to  be  constricted  when  the  muscle  contracts ;  also  there  are 
no  valves  in  the  superior  hemorrhoidal  veins,  and  hardened  feces 
are  likely  to  press  on  them  and  stroke  the  blood  downward,  away 
from  the  heart.  The  mucous  membrane  is  thick  and  loosely  con- 
nected to  the  muscular  coat  beneath,  thus  favoring  prolapse, 


FIG.  GO. — Short  Proctoscope. 

especially  in  the  child,  where  the  rectum  is  straighter  than  in  the 
adult. 

The  reflex  contractions  of  the  sphincter  prevent  healing  of  a 
fissure  and  are  a  source  of  pain.  They  also  prevent  an  ischio-rectal 
abscess  from  closing  and  convert  it  into  a  fistula.  Because  over- 
developed by  its  activity  in  such  cases,  the  sphincter  is  especially 
strong;  therefore  it  must  be  thoroughly  stretched  to  the  point  of 
temporary  paralysis  before  any  operative  procedure  can  be  under- 
taken with  the  hope  of  a  successful  outcome. 

Digital  Examination. — The  well-anointed  left  forefinger  is  passed 
into  the  anus,  the  direction  being  first  forward  toward  the  vagina 
and  then  backward.  If  the  patient  bears  down  as  the  tip  of  the 
finger  passes  through  the  anus,  the  sphincter" is  relaxed  and  the 
anal  canal  is  straightened.  Thus  the  discomfort  is  lessened  while 
the  finger  is  introduced  gradually  with  a  boring  motion.  The  an- 


124  THE  INVESTIGATION  OF  THE  RECTUM 

tiTior  and  side-walls  of  the  ampulla  arc  palpated.  A  lesion  on  the 
anterior  wall  is  felt  between  the  left  forefinger  in  the  rectum  and 
the  right  forefinger  in  the  vagina.  The  strength  of  the  sphincter 
ani  is  estimated,  spasm,  due  to  long-continued  irritation,  areas  of 
induration,  ulceration,  or  narrowing  of  the  caliber  of  the  gut,  and 
the  presence  of  tumors  are  determined.  A  general  smoothness  and 
absence  of  folds  indicates  atony. 

The  right  forefinger,  in  like  manner,  is  used  to  palpate  the 
posterior  wall  of  the  ampulla.  The  presence  of  internal  piles  is 
very  hard  to  diagnosticate  by  touch.  The  proctoscope  must  be 
used  for  these.  In  making  the  digital  examination  it  is  well  to 
pass  the  unused  fingers  of  the  examining  hand  between  the  nates, 
or  over  the  vulva  and  the  thumb  beside  the  vulva  or  between  the 


FIG.  61. — Long  Proctoscope. 

nates,  for  in  this  way  a  greater  distance  can  be  reached  in  the 
rectum  than  by  shutting  the  unused  fingers  on  the  palm  of  the 
hand.  If,  after  the  digital  examination,  the  diagnosis  is  still  in 
doubt,  the  Kelly  proctoscope  should  be  used. 

Proctoscopy. — A  good  light,  preferably  an  electric  light  and 
a  head  mirror,  are  necessary,  just  as  in  cystoscopy.  The  patient  is 
put  in  the  knee-chest  position.  Something  as  to  the  condition  of 
the  anal  canal  may  be  learned  by  the  use  of  the  smallest-size  Sims 
vaginal  speculum  in  the  anus  and  some  physicians  report  good 
results  with  it.  Personally,  I  have  not  found  it  valuable  as  a 
means  of  diagnosis  unless  the  sphincter  has  been  first  stretched. 
The  Sims  rectal  speculum  is  adapted  only  for  use  with  the  patient 
anesthetized. 

Two  proctoscopes  are  sufficient  for  diagnostic  purposes.     The 
shorter  one,  three  inches  (7.o  centimeters)  long  by  seven-eighths 


PROCTOSCOPY  125 

inch  (2.3  centimeters)  in  diameter,  is  passed  first.  It  is  thoroughly 
anointed  and  introduced  slowly  while  the  patient  bears  down. 
The  physician  keeps  in  mind  the  direction  of  the  anal  canal  and  the 
rectum  proper;  the  tip  of  the  proctoscope  with  its  obturator  in 
place  is  pointed  first  downward  toward  the  pubes,  then  inward  in 
the  axis  of  the  body  after  the  sphincter  has  been  passed,  and  then 
upward  toward  the  sacrum.  Remember  the  situation  of  the 
valves  of  the  rectum  and  work  the  tip  of  the  proctoscope  by  them 
gradually.  Removing  the  obturator  air  rushes  in,  balloons  the 
rectum,  and  permits  a  view  of  the  lower  part  of  this  organ.  The 
alligator  forceps  are  useful  to  remove  bits  of  fecal  matter  or  to 
wipe  away  secretion  with  cotton  pledgets,  or  to  obtain  tissue  for 
microscopic  examination.  As  the  proctoscope  is  withdrawn  the 
internal  and  external  sphincters  are  inspected  as  they  roll  into  the 
lumen  of  the  proctoscope.  The  longer  proctoscope,  five  and  a 


FIG.  62. — Long  Alligator  Forceps. 

half  inches  (14  centimeters)  long  by  seven-eighths  inch  (2.3  centi- 
meters) in  diameter,  is  of  value  to  inspect  the  upper  rectum.  The 
sigmoicloscope  is  a  dangerous  instrument,  for  although  by  its  use, 
in  favorable  cases,  a  glimpse  of  the  sigmoid  may  be  obtained,  it 
is  likely  to  injure  the  bowel. 

In  introducing  the  longer  proctoscope  it  is  advisable  to  remove 
the  obturator  after  the  sphincter  has  been  passed  and  to  carry  the 
instrument  higher  in  the  rectum  by  sight.  The  semilunar  valves 
can  be  seen  and  avoided  by  the  advancing  edge  of  the  proctoscope. 
Remember  that  the  empty  rectum  is  normally  contracted — that 
is  to  say,  its  walls  are  in  apposition — therefore  this  state  must 
not  be  mistaken  for  stricture.  The  air  sometimes  does  not  separate 
the  walls  of  the  upper  rectum,  although  it  does  those  of  the  ampulla. 

The  mucous  membrane  of  the  rectum  is  studded  by  branching 
vessels  and  the  openings  of  little  glands  may  be  seen.  Inflamma- 
tion is  marked  by  a  diffuse  velvety  injected  appearance  of  the 


120  THE  INVESTIGATION  OF  THE  RECTUM 

mucosa,  together  with  the  disappearance  of  the  normal  branching 
vessels;  ulcerations  are  easily  distinguished,  polypi  may  be  seen 
hanging  from  the  rectal  wall,  or  the  bleeding  surface  of  a  carcinoma 
may  obstruct  the  lumen  of  the  proctoscope.  If  there  is  stricture 
of  the  bowel  because  of  syphilis,  or  cancer,  a  smaller  proctoscope 
should  be  used.  A  large-sized  Kelly  cystoscope  will  often  serve 
instead  of  a  proctoscope  in  such  cases,  also  in  the  examination  of 
the  rectum  in  children. 

Stretching  the  Sphincter  and  Speculum  Examination  of  the  Rectum. 
In  exceptional  cases  it  is  necessary  to  give  an  anesthetic  in  order 
to  make  a  complete  diagnosis  of  rectal  disease.  In  such  an  event, 
after  the  patient  is  thoroughly  anesthetized  she  is  placed  in  the 


FIG.  63. — Sims  Rectal  Speculum. 

Sims  position;  the  operator  anoints  both  thumbs  and  inserts  them 
through  the  anus.  By  means  of  the  fingers  grasping  both  buttocks 
gentle  but  firm  traction  is  made  on  the  sphincter  ani.  A  good  deal 
of  time  should  be  devoted  to  the  stretching  of  the  sphincter,  some 
fifteen  minutes.  Rapid  and  forcible  stretching  is  very  apt  to 
result  in  rupture1  of  the  muscle  followed  by  partial  or  complete 
permanent  incontinence  of  feces  or  in  fissure  of  the  mucous 
membrane.  Thorough  stretching  of  the  sphincter  is  an  essential 
for  any  instrumentation  of  the  rectum  except  proctoscopy.  After 
the  preliminary  stretching  the  sphincter  muscle  is  fixed  between  the 
thumb  and  forefinger  of  the  left  hand  and  successive  portions  of 
its  periphery  are  stretched  by  the  thumb  and  forefinger  of  the  right 
hand.  The  Sims  rectal  speculum  is  passed  and  light  is  reflected 
into  the  rectum  by  the  head  mirror,  the  alligator  forceps  and  pled- 
gets of  cotton  being  used  to  wipe  away  discharges  and  feces. 


CHAPTER  X. 

THE  SIGNIFICANCE  OF  THE  CHIEF  SYMPTOMS  OF 
PELVIC  DISEASE. 

Dysmenorrhea,  p.  128:  Frequency,  p.  128;  Menstrual  inolimena,  p. 
128.  I.  Dysmenorrhea  associated  with  pelvic  lesions,  p.  129:  Congenital 
malformations,  Retroposition  with  anteflexion,  Pelvic  inflammation,  Fibroids, 
p.  129.  II.  Dysmenorrhea  where  no  pelvic  lesion  can  be  found,  p.  130: 
Neurotic  dysmenorrhea,  Dysmenorrhea  due  to  poor  general  health,  p.  130. 
Membranous  dysmenorrhea,  p.  130. 

Intermenstrual  pain,  p.  132:     Description,  p.  132.     Etiology,  p.  133. 

Menorrhagia  and  Metrorrhagia,  p.  134 :  I.  Constitutional  causes,  p.  135. 
II.  Local  causes,  p.  135:  1.  The  patient  is  a  virgin,  p.  136;  Table  of  men- 
orrhagia and  metrorrhagia  in  virgins,  p.  137;  2.  The  patient  is  not  a  virgin 
and  (a)  has  never  been  pregnant,  p.  137,  (6)  has  been  pregnant,  p.  138;  (c)  is 
pregnant,  p.  138;  Table  of  menorrhagia  and  metrorrhagia  in  married  women, 
p. 139. 

Amenorrhea,  p.  139:  1.  Primary  amenorrhea,  p.  139:  Due  to  (a)  Failure 
of  growth,  p.  139;  (b)  Atresia  of  the  hymen  or  of  the  vagina,  p.  140.  2. 
Secondary  amenorrhea,  p.  141 :  Due  to  (a)  Pregnancy  and  lactation,  p.  141; 
(b)  Atrophy  of  the  ovaries,  p.  141;  (c)  Constitutional  diseases,  p.  141;  (d) 
Exhaustion  and  shock,  p.  142;  (e)  Retention  of  menses  from  acquired  atresia 
of  the  genital  canal,  p.  142. 

Leucorrhea,  p.  143:  Character  of  the  discharge,  p.  143:  White  dis- 
charge, p.  143;  Yellow  discharge,  p.  143;  Watery  discharge,  p.  144;  Fetid 
discharge,  p.  144;  Bloody  discharge,  p.  144.  Occurrence  of  leucorrhea,  p. 
144:  Leucorrhea  in  children,  p.  144;  Leucorrhea  in  virgins,  p.  145;  Leu- 
corrhea in  married  women,  p.  145;  Leucorrhea  in  old  women,  p.  146. 

Dyspareunia,  p.  146:  1.  Psychical  causes,  p.  146.  2.  Anatomical 
causes,  p.  146. 

Sterility,  p.  147:  Absolute,  p,  147;  Secondary,  p.  147;  Facultative,  p, 
147.  Sterility  in  the  male,  p.  148.  Sterility  in  women,  p.  148:  Age  as  a 
factor,  ]>.  148;  Other  factors,  p.  149,  Anomalies  and  diseases  of  the  uterine 
organs,  p.  150;  Conditions  of  the  uterine  organs  that  cause  interruption  of 
pregnancy,  p.  150,  Constitutional  diseases  and  general  causes,  p.  151. 

Vesical  symptoms,  p.  151 :  1.  Dysuria,  p.  151;  General  causes  and  local 
causes,  p.  152.  2.  Too  frequent  urination,  p.  153.  3.  Incontinence  of 
urine,  Enuresis,  p.  154:  Local  causes,  p.  154;  General  causes,  p.  155; 
Nocturnal  enuresis,  p.  155.  4.  Retention  of  urine,  Ischuria,  p.  155.  5. 
Suppression  of  urine,  Anuria,  p.  156. 

Rectal  symptoms,  p.  15(5:  Pain,  p.  156.  Hemorrhage,  p.  157.  Rectal 
discharge,  p.  157.  Fecal  accumulation,  p.  157.  Difficulty  in  defecation,  p. 
158.  Protrusion  from  the  anus,  p.  158.  Character  of  the  feces,  p.  158. 

127 


128  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

Coccygodynia,  p.  1.59:  Etiology  and  pathology,  p.  159.  Symptoms,  p. 
159.  Diagnosis,  p.  HJO. 

Pruritus  vulvae,  p.  1(!0.  Caused  by:  1.  Irritating  discharges  from  the 
vagina  or  bladder,  p.  160;  2.  Diseases  of  the  vulva,  p.  161;  3.  Neuroses, 
p.  161. 

DYSMENORRHEA 

THE  term  dysmenorrhea  (from  <^?,  difficult,  i^v}  month,  and 
/''££",  to  flow)  .signifies  painful  menstruation,  and  is  used  to 
define  suffering  of  whatever  kind  associated  with  the  performance 
of  the  function  of  menstruation.  In  spite  of  the  many  theories 
advanced  to  explain  the  occurrence  of  pain  accompanying,  preced- 
ing, or  following  the  monthly  flow,  we  are  still  ignorant  of  the  cause. 
Authorities  are  not  agreed  as  to  the  frequency  of  pain  among 
normal  women.  Theoretically  the  woman  should  be  conscious  of 
menstruation  only  by  the  discharge  of  blood  from  the  vulva;  as 
a  matter  of  fact  a  considerable  proportion  of  women  have  some  sort 
of  discomfort.  Marie  Tobler  (Monatsschr.  fur  Geburts.  und  Gyn., 
1905,  Vol.  XXII.,  p.  1)  investigated  this  question  in  the  case  of 
one  thousand  and  twenty  women  and  found  that  twenty-six  per 
cent  had  local  pain,  general  discomfort,  malaise,  weakness,  or 
mental  disturbance  at  menstruation.  Some  writers  place  the 
percentage  of  local  or  general  discomfort  as  high  as  sixty  or  seventy 
per  cent  of  all  women.  It  is  to  be  remembered,  however,  that 
most  of  the  data  come  from  investigators  who  have  to  do  with 
women  afflicted  with  uterine  disease  and  not  with  normal  women. 

Menstrual  molimina  are  the  local  and  general  disturbances  that 
are  supposed  to  be  normal  to  menstruation;  they  are: — a  certain 
amount  of  pain  in  the  pelvis  extending  through  the  back  and  thighs, 
also  nervous  depression,  resulting  in  lassitude,  headache,  nervous 
instability,  and  derangement  of  the  function  of  different  organs. 

Some  of  the  last  are:  eye  strain,  skin  eruptions — such  as  urticaria 
and  acne, — pains  in  the  joints,  and  loosening  of  the  sacro-iliac 
joint  in  the  case  of  sacro-iliac  disease,  and  various  sorts  of  " neu- 
ralgias." They  are  often  spoken  of  as  "reflex  symptoms."  Ex- 
aggeration of  the  menstrual  molimina  constitutes  dysmenorrhea, 
although  the  term  is  more  often  applied  to  the  actual  pain  which 
is  referred  to  the  pelvis  than  to  the  more  distant  manifestations. 

Dysmenorrhea  may  be  classified  as  of  two  sorts,  (1)  that  associ- 


DYSMENORRHEA  129 

atcd  with  definite  discoverable  lesions  of  the  uterine  organs,  and 
(2)  that  in  which  no  abnormality  of  those  organs  can  be  deter- 
mined. 

1.  DYSMENORRHEA  ASSOCIATED  WITH  PELVIC  LESIONS 

This  includes  dysmeriorrhea  occurring  in  the  case  of  (1)  Con- 
genital malformations  of  the  uterine  organs,  (2)  retroposition  with 
anteflexion,  (3)  pelvic  inflammation,  and  (4)  fibroids. 

1.  Congenital   Malformation  of  the   Uterine   Organs. — A   woman 
having  an  infantile  uterus  or  a  congenitally  anteflexed  uterus  is 
apt  to  suffer  with  dysmenorrhea,  so  also,  in  the  case  of  atresia  of 
the  vagina  or  of  the  uterus  where  the  ovaries  are  at  the  same  time 
well  developed,  pain  recurring  at  regular  intervals  is  apt  to  be  a 
constant  symptom. 

2.  Retroposition  with  Anteflexion. — Dysmenorrhea  is  the  rule  with 
this  affection,  especially  in  the  case  of  the  unfruitful.     The  pain 
in  these  cases  generally  begins  with  the  appearance  of  the  flow,  it 
is  cramp-like,  and  is  relieved  after  the  flow  has  become  well  estab- 
lished.    Frequent  and  painful  micturition  is  often  associated  with 
this  malposition,  whatever  the  cause  may  be. 

This  is  a  sort  of  uterus  in  which  the  so-called  obstructive  dysmen- 
orrhea was  supposed  by  Marion  Sims  and  his  followers  to  occur. 
This  theory  is  that  the  escape  of  the  menstrual  discharges  is  impeded 
by  the  flexing  of  the  uterine  canal  by  a  stenosis  either  of  the  internal 
or  the  external  os,  by  an  intra-uterine  polyp  acting  like  a  ball- 
valve,  or  by  clots  of  blood.  At  the  present  time  the  best  authori- 
ties are  agreed  that  actual  obstruction  seldom  exists. 

3.  Pelvic  Inflammation. — Pelvic  inflammation  includes  endome- 
tritis,  and  also  pelvic  peritonitis,  salpingitis,  ovaritis,  and  a  certain 
amount  of  cellulitis.     In  the  acute  stages  of  pelvic  inflammation 
dysmenorrhea  is  a  fairly  common  symptom — perhaps  in  from  a 
third  to  n  half  of  all  cases.     In  the  chronic  stages  it  causes  uterine 
malposition   and   chronic   endometritis,   which  are  more   directly 
causative  of  painful  menstruation.     The  pain  is  apt  to  antedate 
the  beginning  of  the  flow  and  lasts  through  the  entire  period. 

4.  Fibroids. — Dysmenorrhea  is  a  fairly  constant  accompaniment 
of  submucous  and  interstitial  myonmta.     It  is  rare  in  the  sub- 
peritoneal  sort.     The  size  of  the  tumor  bears  no  definite  relation 

9 


130  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

to  the  amount  of  the  pain  experienced;  often  the  pain  is  most 
severe  in  the  case  of  very  small  tumors.  The  pain  in  the  uterus 
itself  must  he  differentiated  from  the  more  or  less  constant  pain 
due  to  pressure  by  large  tumors  on  the  surrounding  nerves  in  the 
pelvis.  The  pain  in  the1  uterus,  according  to  Kelly  and  Cullen 
("Myomata  of  the  Uterus"),  is  most  severe  at,  or  just  before,  the 
menstrual  period.  The  pain  from  pressure  is  apt  to  be  in  the  legs 
and  feet  and  mav  be  mistaken  for  rheumatism. 


II.    DYSMEXORRHEA    WHERE    xo    PELVIC    LESION    CAN    BE 

FOUND 

Dysmenorrhea  often  exists  in  women  who,  apparently,  have 
perfectly  normal  uterine  organs.  In  this  event  the  painful  men- 
struation is  (1)  neurotic,  or  (2)  due  to  poor  general  health. 

1.  Neurotic  Dysmenorrhea. — Neurotic  clysmenorrhea  appears  to 
be  due  to  excessive  sensitiveness  of  the  endometrium.     The  uterine 
contractions  occurring  during  menstruation  cause  abnormal  pain, 
something  like  the  after-pains  of  labor.     The  formation  of  clots  in 
the  uterine  cavity,  exciting  expulsive  contractions  and  pain,  has 
been  assumed  to  bo  the  cause  in  some  cases,  but  there  are  no  facts 
to  substantiate  this  theory.     Dysmenorrhea  is  often  observed  in 
cases  of  neurasthenia  and  sometimes  in  patients  with  this  disease 
who  previously  had  not   had  painful  menses.     The  physician  is 
often  left  in  doubt  which  is  cause  and  which  effect  in  the  investiga- 
tion of  neurasthenia  and  dysmenorrhea. 

2.  Dysmenorrhea  Due  to  Poor  General  Health. — Dysmenorrhea  is 
observed  frequently  in  girls  under  twenty  who  are  the  subjects  of 
anemia  or  chlorosis.     There  are  no  satisfactory  theories  among  the 
many  that  have  been  advanced  to  explain  this  association  of  men- 
strual suffering  with  these  two  diseases. 

Membranous  Dysmenorrhea. — Membranous  dysmenorrhea  is 
characterized  by  severe  cramp-like  pains  in  the  lower  abdomen 
and  back,  resembling  labor  pains,  occurring  at  the  time  of  men- 
struation and  followed  by  the  expulsion  of  a  more  or  less  incomplete 
cast  of  the  cavity  of  the  corpus  uteri  in  the  shape  of  a  sac,  triangular 
in  form,  grav  in  color,  and  ha  vim:  a  rough  surface.  When  floated 


MEMBRANOUS  DYSMENORRHEA  131 

in  water  and  laid  open,  the  interior  of  the  sac  is  smooth.  With 
the  aid  of  a  magnifying  glass  this  smooth  surface  is  seen  to  be 
studded  with  minute  openings  which  represent  the  mouths  of  the 
utricular  glands.  If  the  sac  is  reasonably  complete — it  is  seldom 
entire — the  openings  of  the  Fallopian  tubes  may  be  distinguished 
in  the  upper  corners.  The  membrane  is  from  one  to  three  milli- 
meters thick  and  under  the  microscope  shows  much  the  appear- 
ance of  exudative  interstitial  endometritis,  although  the  patho- 
logical characteristics  of  the  membrane  are  not  constant;  therefore 
membranous  dysmenorrhea  is  not  a  definite  disease  but  a  condition 
which  exists  in  the  presence  of  different  pathological  processes. 

The  etiology  of  this  disease  is  shrouded  in  mystery.  As  far  as 
known,  endometritis  precedes  membranous  dysmenorrhea  in  a 
large  proportion  of  cases.  In  certain  cases  menstruation  is  normal 
and  regular  until  infection  occurs  following  abortion  or  labor;  then 
membranous  dysmenorrhea  develops  in  the  course  of  a  few  months. 
In  another  class  of  cases,  many  of  them  being  unmarried  women, 
menstruation  is  normal  and  regular  and  the  painful  menstruation 
with  the  expulsion  of  a  membrane  develops  without  any  apparent 
cause.  Following  the  expulsion  of  the  membrane  there  is  generally 
a  profuse  flow  of  blood. 

In  making  a  diagnosis  of  membranous  dysmenorrhea  we  must 
exclude  (a)  decidual  endometritis  and  (6)  exfoliative  vaginitis. 

(a)  In  the  case  of  decidual  endometritis  there  is  a  history  of 
pregnancy,  also  some  of  the  signs  of  pregnancy  or  extra-uterine 
pregnancy  should  be  present  (see  Chapters  XXII  and  XIX). 
Hemorrhage  following  the  expulsion  of  the  membrane,  or  parts  of 
it,  generally  lasts  longer  and  is  more  profuse  than  is  the  case  with 
membranous  dysmenorrhea.  The  cast  of  the  uterine  cavity  is 
larger  and  more  vascular  than  in  the  case  of  the  membrane  of  dys- 
menorrhea, and  chorionic  villi  should  be  visible  when  the  specimen 
is  examined  under  the  miscroscope. 

(6)  Exfoliative  vayinitix  may  accompany  membranous  dysmen- 
orrhea, the  exfoliation  of  the  vagina  being  a  part,  apparently,  of 
the  same  pathological  process  which  causes  the  casting  off  of  the 
endometrium.  Such  an  association,  although  authoritatively 
reported,  must  be  considered  as  very  rare.  Exfoliative  vaginitis 
occurring  as  a  result  of  inflammation  or  from  treating  the  vagina 
with  strong  caustics,  such  as  nitrate  of  silver  (see  Chapter  XX,  page 


132  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

364),  is  a  not  uncommon  disease,  and  if  the  lining  mucosa  is  thrown 
off  at  the  time  of  a  menstruation  which  is  accompanied  by  cramps, 
the  physician  must  be  able  to  distinguish  between  a  cast  from  the 
vagina  and  one  from  the  uterine  cavity. 

A  vaginal  cast  when  floated  in  water  does  not  present  a  tri- 
angular shape  and  no  tubal  openings  are  to  be  seen.  However,  as 
all  casts  are  often  expelled  in  pieces,  these  features  may  be  absent 
in  both  cases.  On  examining  a  vaginal  cast  with  a  magnifying 
glass  it  will  be  seen  to  have  a  surface  that  is  relatively  rough  and 
there  arc  no  openings  of  glands  in  it.  Microscopic  examination 
shows  it  to  be  made  up  of  stratified  vaginal  epithelium  and  the 
characteristic  glandular  structure  of  the  endometrium  is  absent. 


INTERMENSTRUAL    PAIN 

Intcrmcnstrual  pain,  or  "Mittelschmerz,"  is  the  name  given  to 
pain  similar  to  the  pain  of  dysmenorrhea,  occurring  on  a  definite 
date  between  two  menstrual  periods,  often  midway  between,  but 
not  always. 

This  affection  is  by  no  means  uncommon  and  every  gynecologist 
of  wide  experience  has  met  with  several  cases.  Dr.  H.  A.  Kelly 
("Medical  Gynecology  ")  has  collected  sixty-four  cases  from  his  own 
experience  and  the  literature,  and  I  will  summarize  his  conclusions 
from  an  analysis  of  these  cases. 

As  a  rule  intermenstrual  pain  does  not  begin  with  the  first 
menstruation,  but  is  generally  noted  during  the  period  of  full  sexual 
activity,  that  is,  between  the  years  of  twenty  and  thirty-five.  In 
a  majority  of  cases  it  is  associated  with  sterility,  but  in  a  large 
proportion  of  the  child-bearing  women  who  are  the  subjects  of  this 
pain,  pregnancy  seems  to  stand  in  a  causal  relation  to  the  inter- 
menstrual  pain. 

Three  cases  of  intermenstrual  pain  have  been  reported  in  which, 
pregnancy  supervening,  the  pain  ceased  entirely  during  pregnancy 
and  during  lactation,  only  to  return  on  the  re  establishment  of 
menstruation. 

The  pain  always  occurs  about  the  middle  of  the  intorincnstmal 
period  and  extends  into  the  second  half  of  it,  and  the  date  of  the 
intermenstrual  pain  seems  to  depend  on  the  date  of  the  beginning 


1NTERMENSTRUAL  PAIN  133 

of  the  following  menstrual  period  and  not  on  that  of  the  preceding 
period. 

Exact  data  as  to  the  beginning  of  regular  menstruation  and  the 
beginning  of  the  intermenstrual  pain  should  be  made  in  every  case 
for  record.  The  character  of  the  pain  varies  in  individual  cases, 
it  may  be  dull  or  it  may  be  sharp;  it  is  seldom  paroxysmal.  It  is 
situated  in  the  pelvic  region,  just  as  in  dysmenorrhea.  The  pain 
lasts  from  a  few  days,  up  to  the  entire  time  from  its  beginning  until 
the  next  menstruation.  It  generally  lasts  three  or  four  days. 

Intermenstrual  pain  may  be  present  during  all  of  a  woman's 
menstrual  life.  We  have  no  assurance  that  it  will  cease  short  of 
the  menopause.  It  does  not  seem  to  be  associated  with  dysmenor- 
rhea, although  precise  information  on  this  point  is  lacking,  as  it  is 
on  the  question  of  its  association  with  regularity  and  irregularity 
of  menstruation.  There  is  a  very  great  probability  that  many  cases 
rated  as  irregularity  of  painful  menstruation  would,  if  analyzed 
carefully,  be  found  to  be  cases  of  intermenstrual  pain. 

In  a  majority  of  cases  of  intermenstrual  pain  the  suffering  is 
accompanied  by  a  vaginal  discharge,  either  as  a  watery  leucorrhea, 
or  a  yellowish  or  blood-stained  discharge.  Often,  a  uterine  lesion, 
such  as  endometritis,  a  polyp,  or  a  submucous  fibroid  will  be  found 
to  explain  the  leucorrhea.  As  a  rule,  no  definite  relation  has  been 
established  between  pelvic  lesions  and  intermenstrual  pain. 

As  regards  the  causation  of  this  affection,  Kelly  is  inclined  to 
agree  with  Sir  William  Priestly,  who  first  reported  four  cases  of  the 
disorder  in  1871  (Brit.  Med.  Jour.,  Vol.  II.,  p.  683).  His  theory 
is  that  under  normal  conditions  previous  to  menstruation,  one  or 
both  ovaries  become  congested,  the  congestion  persisting  through 
menstruation  and  for  a  few  days  after.  This  congestion  is  attended 
by  no  signs.  Under  abnormal  conditions,  because  of  changes 
in  the  ovaries  not  understood,  the  congestion  begins  earlier 
than  usual  and  is  attended  by  pelvic  pain.  Therefore  the  pain 
has  relation  to  the  coming  period  and  not  to  that  which  has 
preceded  the  pain.  In  the  cases  observed  clinically  such  a  relation 
is  found  to  exist. 

Physicians  are  urged  to  report  cases  of  intermenstrual  pain  with 
exactness  so  that  data  may  be  in  hand  as  to  this  interesting  and 
neglected  affection.  Besides  the  patient's  age  and  social  condition, 
the  following  points  should  be  noted: — (1)  Day  of  the  month  on 


134  THK   CHIEF  SYMPTOMS   OF   PELVIC   DISEASE 

which  the  last  menstruation  began.     (2)  Date  at  which  intermen- 

strual  pain  began.  (3)  Date  at  which  the  following  catamenia 
began.  (4)  Length  of  time  the  pain  lasts,  and  its  character.  (5) 
Date  when  interrnenstrual  pain  was  first  noted.  (6)  Full  details 
of  a  normal  menstruation,  i.e.,  exact  interval  between  beginning  of 
each  two  catamenia,  duration  of  the  flow  in  days,  amount  of  flow 
in  napkins  each  day,  occurrence  of  pain  and  leucorrhea.  (7) 
Whether  or  not  intermenstrual  pain  is  attended  by  a  vaginal  dis- 
charge, and  if  so,  its  amount  and  character.  (8)  If  a  pelvic  exam- 
ination has  been  made,  note  the  findings. 


MENORRHAGIA  AND  METRORRHAGIA 

Menorrhagia  (monthly  bleeding,  from  /«>£?,  menses,  and 
<'w'»u'.,  to  burst  forth)  an  excessive  loss  of  blood  at  the  men- 
strual periods,  and  metrorrhagia  (uterine  bleeding,  from  ttfTpa, 
womb,  and  farSw.,  to  burst  forth)  a  loss  of  blood  independent 
of  menstruation,  are  two  terms  which  frequently  can  not  be  used 
with  discrimination  because  the  two  conditions  so  often  coexist. 
That  is  to  say,  a  metrorrhagia  becomes  a  menorrhagia  when  the 
menstrual  period  arrives,  and  menorrhagia,  as  in  the  case  of  a 
submucous  fibroid,  in  the  course  of  time  becomes  a  metrorrhagia. 
Therefore  it  will  be  convenient  to  consider  the  two  symptoms 
together,  bearing  in  mind  the  fact  that  menorrhagia  may  be  due 
to  constitutional  disease,  whereas  metrorrhagia  is  always  due  to 
disease  of  the  pelvic  organs.  Mcnorrhayia  is  a  relative  term,  for 
what  is  a  moderate  How  for  one  woman  would  be  rated  as  excessive 
by  another.  Therefore,  before  pronouncing  that  menorrhagia 
exists  in  any  given  case,  the  physician  must  inquire  minutely  as  to 
the  patient's  normal  habit  of  menstruation,  getting  the  number  of 
days  that  the  How  lasts,  and  the  number  and  size  of  the  napkins 
used,  and  whether  they  are  well  saturated  or  not.  As  a  rule, 
under  normal  conditions,  most  of  the  How  occurs  during  the  first 
two  or  three  days.  Find  out  whether  this  is  the  case.  Supposing 
that  it  is,  a  loss  of  blood  of  a  like  amount,  lasting  through  five  or 
six  days,  would  constitute  menorrhagia.  If  the  How  is  increased 
during  the  normal  menstrual  time  it  is  one  type  of  menorrhagia, 
and  a  menstruation  unduly  prolonged  in  point  of  time  is  another. 


MENORRHAGIA  AND  METRORRHAGIA  135 

Only  painstaking  questioning,  or  the  results  of  observation  by  a 
nurse,  will  establish  the  facts.  .   . 

In  investigating  a  case  of  menorrhagia  the  constitutional  causes 
should  be  considered  first,  then  the  local  causes.  Only  the  habit 
of  excessive  menstruation — not  for  one  or  two  periods  only — should 
necessitate  a  diagnosis,  and,  particularly  in  the  case  of  unmarried 
girls  and  women,  constitutional  diseases  must  be  eliminated  care- 
fully before  proceeding  to  local  examination.  The  establishment  of 
menstruation  at  puberty  is  frequently  attended  by  menorrhagia 
for  several  periods.  Family  tendencies  are  to  be  borne  in  mind. 
In  some  families  it  is  the  habit  for  the  women  to  flow  freely,  and  in 
others  the  reverse  holds  true. 


I.  CONSTITUTIONAL  CAUSES  OF  MENORRHAGIA 

The  following  blood  conditions  are  known  to  be  attended  by 
menorrhagia: — hemophilia,  purpura,  scurvy,  leukemia,  the  uremia 
of  nephritis,  and  severe  cholemia  or  jaundice.  The  various  in- 
fectious diseases,  such  as  small-pox,  scarlet  fever,  cholera,  typhoid 
fever,  influenza,  and  malarial  fever,  often  have  excessive  menstrua- 
tion as  a  symptom.  Menorrhagia  is  not  uncommon  in  the  early 
stages  of  pulmonary  phthisis,  although  amenorrhea  is  the  rule  in 
this  disease.  It  also  occurs  in  syphilis  and  in  the  chronic  poison- 
ings of  alcohol,  lead,  or  phosphorus,  and  in  organic  heart  disease 
and  in  cirrhosis  of  the  liver.  An  excessive  menstrual  flow  is  apt 
to  attend  the  initial  stages  of  any  acute  constitutional  disease. 
Heart  disease  favors  climacteric  hemorrhage, — a  feeble  or  an  in- 
sufficient heart  making  for  pelvic  congestion  with  consequent 
menorrhagia  or  metrorrhagia. 


II.    LOCAL   CAUSES   OF   MENORRHAGIA   AND   METRORRHAGIA 

Having  ruled  out  the  constitutional  causes  of  menorrhagia,  the 
physician  should  make  a  careful  vaginal  examination  in  all  cases  of 
persistent  uterine  hemorrhage,  whether  occurring  at  the  menstrual 
periods  or  not. 

The  local  causes  may  be  enumerated  as  follows: — 

Uterine  congestion. 


130  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

Endomotritis. 
Polypi. 

Abortion. 

Extra-uterine  pregnancy. 

Subinvolution  of  the  uterus. 

Submucous  fibroids. 

Cancer  of  the  cervix. 

Cancer  of  the  fundus. 

Sarcoma. 

Chorio-epithelioma. 

Inversion  of  the  uterus. 

Backward  displacements  of  the  uterus. 

Inflammation  of  the  tubes  and  ovaries. 

Small  cystic  degeneration  of  the  ovaries. 

Ovarian  cyst  with  twisted  pedicle. 

Arterio-sclerosis  of  the  uterine  blood-vessels. 

Yaginitis  and  injuries  of  the  vulva  and  vagina. 

It  may  be  well  here  to  point  out  the  probable  diagnosis  to  be 
obtained  from  the  patient's  age,  whether  or  not  she  is  a  virgin,  or 
whether  or  not  she  has  ever  been  pregnant. 

The  following  affections  are  common  to  the  virgin,  the  married 
woman,  and  the  multipara: — ovarian  tumors,  fibroids,  and  cancer 
and  sarcoma. 

Arterio-sclerosis  of  the  small  blood-vessels  of  the  uterus  has  been 
described  by  Henri  Arnal,  Palmer  Findley,  and  others.  It  is 
essentially  a  disease  of  the  senile  uterus,  although  cases  have  been 
reported  in  the  uteri  of  women  between  thirty  and  forty  years  of 
age.  As  yet  we  do  not  know  how  often  this  condition,  which  seems 
to  be  not  very  uncommon,  is  the  cause  of  hemorrhage. 

1.  The  patient  is  a  virgin,  and  (a)  is  under  the  age  of  twenty-five. 
Increase  in  the  amount  of  menstrual  flow  is  most  often  due  to  uterine 
congestion,  perhaps  brought  on  by  exposure,  or  over-exertion  dur- 
ing a  menstrual  period,  or  it  may  be  due  to  a  glandular  polyp.  In 
the  latter  case,  the  polyp  generally  produces  metrorrhagia  as  well 
as  menorrhagia,  and  thus  we  may  distinguish  between  hemorrhage 
due  to  congestion  and  that  due  to  a  polyp.  Uterine  congestion  is 
the  direct  cause  of  all  uterine  hemorrhage,  the  more  remote  causes, 
such  as  displacements  and  inflammation  of  the  tubes  and  ovaries. 


MENORRHAGIA  AND  METRORRHAGIA         137 

being  many.  Chronic  eridometritis,  formerly  thought  to  be  the 
common  cause  of  uterine  bleeding,  is  now  regarded  as  relatively 
rare,  with  the  exception  of  the  polypoid  and  the  hyperplastic  varie- 
ties. 

(6)  Menorrhagia  may  be  due  to  backward  displacement  of  the 
uterus  at  any  age  before  the  menopause.  From  twenty-five  to 
thirty-five  uterine  fibroids  of  submucous  evolution  are  an  important 
cause  of  both  menorrhagia  and  metrorrhagia.  Cancer,  especially 
cancer  of  the  fundus,  is  to  be  thought  of  as  a  cause  of  metrorrhagia 
after  the  age  of  thirty-five.  A  watery  vaginal  discharge  accom- 
panies the  flow  very  often  in  the  case  of  cancer  of  the  fundus;  some- 
times also  in  fibroids. 

The  facts  may  be  summarized  in  the  following  table: — 


MENORRHAGIA  AND    METRORRHAGIA  IN   VIRGINS. 


AGE.                           MENORRHAGIA.  METRORRHAGIA. 

f  Uterine  congestion.  (  T 

TT    ,                   „  Uterine  polyp. 

Under  twenty-five.  <  .Backward  displacements.  <  „ 

„       ...    . .       ,   ,.  Rarely,  submucous  fibroid. 

^  Constitutional  diseases. 


f  Uterine  congestion.  f  Uterine  polyp. 

Twenty-five  to     j  Endometritis.  j  Submucous  fibroid. 

forty.  I  Backward  displacements,  j  Rarely,  cancer  or  sarcoma  of 

[__  Submucous  fibroid.  [_     the  body  of  the  uterus. 

f  Submucous  fibroid. 
[  bubmucous  fibroid.  J  TTi    . 

-c,  j        ,  .,.  Uterine  polyp. 

~        -     .  Endometritis.  J  „  ,    ., 

Over  forty.       -<  „,     .  ,.  •<  Cancer    or    sarcoma    of    the 

uterine  congestion. 

body  of  the  uterus. 
I  Backward  displacements.  ,  ,, 

^  Rarely,  cancer  of  the  cervix. 


2.  The  patient  is  not  a  virgin,  and  («.)  has  never  been  pregnant. 
When  a  patient  has  been  married  a  short  time  and  gives  a  history 
of  gonococous  infection  with  purulent  vaginal  discharge  and  smart- 
ing on  urination,  the  probability  is  that  if  she  has  menorrhagia  she 
is  suffering  with  gonorrheal  endometritis  and  perhaps  with  pyosal- 
pinx  also.  If  gonoeomis  infection  is  not  present  menorrhagia  in 
such  a  patient  probably  means  uterine  congestion  due  to  excessive 


13S  THE  CHIEF  SYMPTOMS   OF  PELVIC  DISEASE 

sexual  intercourse.  It  may  mean,  however,  a  tear  of  the  hymen 
from  violent  coitus,  or  a  bleeding  urethral  caruncle. 

If  there  are  any  symptoms  of  pregnancy,  such  as  a  preexisting 
amenorrhea  with  sharp  pain  in  one  groin  and  tenesmus,  irregular 
metrorrhagia  might  indicate  extra-uterine  pregnancy.  In  this 
case  look  for  decidual  membrane  in  the  blood  passed  (see  Chapter 
XIX.,  page  344),  or  it  might  mean  an  early  abortion.  The  differen- 
tial diagnosis  of  these  two  conditions  will  be  found  in  Chapter  XXII., 
page  441. 

In  the  absence  of  the  signs  and  symptoms  referred  to,  metror- 
rhagia points  to  a  uterine  polyp. 

Menorrhagia  becoming  gradually  metrorrhagia  in  a  woman  over 
thirty-five  years  of  age  suggests  a  submucous  fibroid,  and  metror- 
rhagia occurring  after  forty,  alwrays  should  arouse  suspicion  of 
malignant  disease ;  sterile  married  women  and  virgins  being  more 
prone  to  cancer  of  the  body  of  the  uterus  than  to  cancer  of  the 
cervix,  and  parous  married  women  to  the  latter. 

(/>)  The  patient  has  been  pregnant.  If  a  pregnancy  is  not  very 
distant  in  the  past,  metrorrhagia  is  probably  due  to  subin volution ; 
if  metrorrhagia  also  is  present,  there  may  be  retained  products  of 
conception,  or  inversion.  Metrorrhagia  coming  on  six  weeks  or 
so  after  labor  may  mean  chorio-epithelioma.  If  pregnancy  was  in 
the  distant  past,  endometritis  in  various  forms,  uterine  displace- 
ments, fibroids,  or  cancer  of  the  cervix  must  be  thought  of.  Metror- 
rhagia beginning  after  the  menopause  has  become  well  established 
almost  invariably  means  cancer. 

(r)  The  patient  is  pregnant.  Uterine  hemorrhage  beginning 
after  one,  two,  or  three  months  .of  amenorrhea,  with  the  occurrence 
of  some  of  the  symptoms  of  pregnancy,  points  toward  threatened 
abortion,  and  if  regular  rhythmic  pains,  like  labor  pains,  are  present 
also,  to  inevitable1  abortion.  (See  Chapter  XXII.,  page  439.) 

Irregular  hemorrhage,  perhaps  with  the  passage  of  decidual 
membrane,  accompanied  by  pain  in  one  groin  and  bearing  down, 
with  any  symptoms  of  pregnancy  may  mean  extra-uterine  preg- 
nancy. (See  Chapter  XIX.,  page1  351.) 

In  the  later  months  of  pregnancy  hemorrhage  may  be  due  to 
placenta  prcvia  or,  rarely,  to  carcinoma  of  the  cervix. 

The  following  table  summarizes  the  facts  as  regards  uterine 
hemorrhage  in  married  women: — • 


PRIMARY  AMENORRHEA 


139 


MENORRHAGIA   AND   METRORRHAGIA   IN  MARRIED   WOMEN. 
MENORRHAGIA.  METRORRHAGIA. 


Multipart. 


Following 
Pregnancy. 


During 

Pregnancy. 


(  Uterine  congestion. 
J  Inflammation    of    tubes 
]       and  ovaries. 
I^Submucous  fibroid. 


Sub-involution. 
Endometritis. 
Submucous  fibroid. 


(  Rarely,  menstruation 
(      during  pregnancy. 


f  Uterine  polyp. 

I  Sub-mucous  fibroid. 

Extra-uterine  pregnancy 
'-\  Ruptured  hymen. 
I  Cancer    or    sarcoma    of    the 

body  of  the  uterus. 
(^Rarely,  cancer  of  the  cervix. 


Retained  products  of  concep- 
tion. 

Cancer  of  the  cervix. 

Inversion. 

Senile  endometritis. 

Chorio-epithelioma. 

Rarely,  cancer  of  the  body  of 
the  uterus. 


C  Threatened  abortion. 
|  Inevitable  abortion. 
•<  Placenta  praevia. 

Extra-uterine  pregnancy. 
|^  Rarely,  cancer  of  the  cervix. 


AMENORRHEA 

Amenorrhca,  or  absence  of  the  menstrual  flow  (from  «,  privative, 
/jty-',  month,  and  fr>^'^,  to  flow),  may  be  classified  as  follows: — (1) 
Primary  amenorrhea,  or  emansio  mensium,  in  which  menstruation 
has  failed  to  appear  at  the  usual  age;  and  (2)  secondary  amen- 
orrhea, or  suppressio  mensium,  in  which  menstruation  has  ceased 
after  it  has  been  established. 

i.  Primary  Amenorrhea. — Primary  amenorrhea  is  due  to  (a) 
failure  of  growth  of  the  uterine  organs,  perhaps  coincident  with 
lack  of  general  bodily  growth,  perhaps  not,  or  to  (6)  atresia  of  the 
hymen  or  of  the  vagina.  The  last  condition,  called  cryptomen,orrhea, 
is,  strictly  speaking,  not  amenorrhea  at  all,  but  a  retention  of  men- 
strual fluid.  As  we  aw  considering  the  symptom  of  absence  of 
menstruation,  it  is  convenient  to  include  cryptomenorrhea  in  this 
place. 

(a)  Failure  of  Growth. — A  girl  having  a  stunted  physique  may 
have  tardy  growth  of  the  uterine  organs  also,  and  menstruation 


140  THE  CM  IKK  SYMPTOMS  OK  PELVIC   DISEASE 

may  appear  later  than  normal.  This,  however,  is  not  so  often  the 
case  as  it  is  to  find  a  good  physique  and  abnormal  uterus  and 
ovaries.  The  uterus  which  exhibits  faults  of  development,  such 
as  uterus  didelphys,  uterus  bicornis,  and  uterus  bipartitus  (see 
Chapter  XIII.,  page1  109),  does  not  ordinarily  have  amenorrhea  as 
a  symptom,  although  rudimentary  uterus,  when  associated  with 
atresia  of  the  vagina,  generally  does.  Arrests  of  growth,  on  the 
other  hand, — infantile  uterus  and  congenital  atrophy  of  the  uterus, 
— are  commonly  attended  by  amenorrhea.  Infantile  uterus  is  a 
relatively  common  condition.  The  uterus  is  narrow  in  proportion 
to  its  length,  has  a  long  cervix  and  a  short  body,  and  is  situated 
well  back  and  high  in  the  pelvis  at  the  end  of  a  long  vagina.  The 
cervix  is  conical  and  anteflexed,  and  the  os  a  " pin-hole  os."  The 
patient's  figure,  breasts,  hair,  and  voice  are  generally  of  the  fem- 
inine type.  Congenital  atrophy  of  the  uterus  is  a  rare  condition. 
Here  all  the  dimensions  of  the  uterus  arc  reduced  while  the  normal 
proportions  are  retained.  The  condition  has  been  found  in  dwarfs 
and  cretins,  and  in  early  tuberculosis  and  chlorosis.  It  is  supposed 
that  in  these  cases  the  uterus  attained  a  proper  growth  to  the 
virgin  type,  and  that  atrophy  followed. 

Both  of  these  conditions  arc  generally  associated  with  anomalies 
of  the  ovaries.  (See  Chapter  XVII.,  p.  28").)  Congenital  absence 
of  both  ovaries  is  extremely  rare.  It  is  of  course  accompanied  by 
absolute  amenorrhea.  Absence  of  one  ovary  does  not  affect  men- 
struation. Faulty  growth  of  the  ovaries  accompanies  both  infantile 
uterus  and  rudimentary  uterus.  The  ovaries  arc  small  and  amen- 
orrhea may  exist. 

(6)  Atresia  of  the  Hymen,  or  of  the  Vagina. — Cryptomenorrhea 
may  be  caused  by  imperf  orate  hymen  (see  Chapter  XXL,  page  390),  or 
by  the  different  varieties  of  atresia  of  the  vagina  (see  Chapter  XX., 
pages  357,  359).  In  these  cases  the  ovaries  are  functionally  active. 
Menstrual  molimina  are  present  and  may  be  attended  by  severe 
cramp  pains,  and  there  may  be  vicarious  menstruation  from  the 
nose  or  other  mucous-mcmbrano-lined  cavities.  The  menstrual 
fluid  collects  behind  the  obstruction,  which  may  be  situated  any- 
where from  the  hymen  to  the  internal  os,  though  it  is  usually  in  the 
vagina,  and  by  distending  first  the  vagina,  then  the  uterus,  and 
finally  the  tubes,  causes  the  conditions  known  as  hematocolpos, 
hcmatometra,  and  hematosalpinx,  respectively. 


SECONDARY  AMENORRHEA  141 

The  patient,  who  has  passed  the  usual  time  for  puberty,  pre- 
sents a  normal  figure  and  has  normal  feminine  breasts,  hair,  and 
voice.  She  complains  of  absence  of  menstruation  arid  suffers  with 
menstrual  molimina — generally  severe  cramps  in  the  lower  ab- 
domen. 

2.  Secondary  Amenorrhea. — The  following  causes  besides  the 
menopause  may  be  enumerated  as  accounting, for  the  cessation  of 
menstruation  after  it  has  been  established: — (a)  pregnancy  and 
lactation,  (6)  atrophy  of  the  ovaries,  (c)  constitutional  diseases. 
(d)  exhaustion  and  shock,  and  (e)  retention  of  menses  from 
acquired  atresia  of  the  genital  canal.  Cessation  of  menstruation 
may  be  temporary  or  permanent;  if  the  latter,  it  constitutes  the 
menopause. 

(a)  Pregnancy  and  Lactation. — Pregnancy  must  be  considered 
the  chief  cause  of  amenorrhea  and  the  physician  will  do  well  to 
bear  this  constantly  in  mind,  even  in  the  cases  where  the  probability 
of  its  being  present  seems  to  be  small.     It  is  to  be  remembered  that 
menstruation  may  occasionally  occur  during  pregnancy  (see  Chap- 
ter XXII.,   page  419).     The  menses  are  usually  absent  during 
lactation,  though  not  always.     Prolonged  lactation  may  induce 
lactation  atrophy  of  the  ovaries  with  consequent  amenorrhea. 

(b)  Atrophy  of  the  Ovaries. — Not  much  is  known  about  the  con- 
ditions which  cause  atrophy  of  the  ovaries.     When  atrophy  has 
taken  place  the  oophoron  of  the  ovary,  the  egg-bearing  zone,  is 
smaller  and  harder  than  normal,  and  becomes  transformed  into  a 
layer  of  dense  fibrous  tissue. 

Ovarian  atrophy  has  been  reported  in  women  who  have  nursed 
their  children  a  very  long  time,  and  also  in  the  following  diseases: — 
the  exanthemata,  myxedema,  marked  anemia,  and  diabetes. 
We  are  justified  in  supposing  that  cessation  of  function  of  the 
ovaries  is  the  direct  cause  of  anienorrhea  in  the 

(f)  Constitutional  Diseases. — Whether  demonstrable  degenera- 
tive tissue  changes  occur  ordinarily  when  amenorrhea  is  present  we 
do  not  know.  There  is  no  doubt  that  the  ovaries  show  a  decrease 
in  size  under  such  conditions. 

Suddenly  acquired  obesity  is  often  attended  by  amenorrhea,  so 
also  arc  the  early  stages  of  pulmonary  phthisis.  In  the  former 
case  it  is  apparently  due  to  anemia  and  over-nutrition,  and  in  the 
latter  to  anemia  and  malnutrition.  Other  instances  of  the  latter 


142  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

cause  are:  tuberculosis  of  the  kidney,  diabetes,  chronic  nephritis, 
malaria,  chronic  mercury,  lead,  or  alcohol  poisoning,  leukemia,  and 
the  morphine  habit. 

If  amenorrhea  is  not  directly  dependent  on  the  blood  state  it  is 
related  to  the  condition  of  the  nervous  system. 

(d)  Mental  overwork  in  schoolgirls  is  sometimes  responsible  for 
the  absence  of  the  menstrual  flow.     Sudden  grief,  worry,  or  fear, 
or  grave  hysteria,  melancholia,  or  some  of  the  other  psychoses,  are 
often  attended  by  amenorrhea. 

(e)  Amenorrhea  from  retained  menstruation  due  to  atresia  of  the 
(jenital  canal  is  comparatively  rare.     Necrosis  of  the  vagina  or 
cervix  following  prolonged  and  difficult  labors,  the  wearing  of 
neglected  pessaries,  or  injury  of  the  vagina  from  caustics,  occasion- 
ally cause  cicatricial  stenosis  to  the  extent  that  the  secretions  of 
the  uterus  are  dammed  up.     In  this  event  the  absence  of  menstrua- 
tion will  be  attended  by  crampy  pains  and  menstrual  molimina. 

If  a  girl  does  not  menstruate  after  she  has  passed  her  sixteenth 
year,  the  physician  should  inquire  into  the  state  of  her  general 
health,  making  whatever  physical  examination  is  necessary  to 
arrive  at  a  diagnosis  of  systemic  disorder.  The  blood  should  be 
examined  both  as  regards  the  number  of  red  corpuscles  and  the 
percentage  of  hemoglobin.  Failing  to  find  any  constitutional  cause 
for  the  amenorrhea,  a  local  examination  should  be  made,  and  except 
in  the  rare  cases  of  phlegmatic  girls  of  good  sense,  with  the  aid  of 
an  anesthetic. 

Should  the  patient  experience  menstrual  molimina  without  a 
flow,  local  examination  should  be  made  without  a  previous  inquiry 
into  the  constitutional  state. 

Neglect  to  investigate  has  resulted  in  serious  harm  in  the  cases  of 
retained  menstruation  from  imperforate  hymen  or  atresia,  through 
dilatation  of  the  uterus  and  tubes  with  rupture  of  the  latter  into 
the  abdominal  cavity. 

In  women  who  have  been  exposed  to  sexual  intercourse,  preg- 
nancy should  always  be  in  the  physician's  mind  as  a  probable  cause 
of  amenorrhea,  and  after  the  fortieth  year  the  possibility  of  the 
beginning  of  the  menopause  should  be  considered. 

In  every  case  of  amenorrhea  the  general  physical  condition  of 
the  patient  should  first  engage  the  physician's  attention, — the 
nervous  svstem  and  the  blood  state  being  thoroughlv  investigated. 


LEUCORRHEA  143 


LEUCORRHEA 


Leucorrhea,  or  "whites"  (from  feoxo?,  white,  and  i»>ia,  flow), 
is  the  generic  name  commonly  given  to  any  discharge  from  the 
vulva,  other  than  blood. 

Under  normal  conditions  the  inner  surface  of  the  vulva  is  simply 
moist  during  the  intermenstrual  time,  except  just  before  and  just 
after  menstruation,  when  the  discharge  may  be  enough  to  necessitate 
wearing  a  napkin.  The  normal  moisture  is  made  up  of  elements 
from  four  different  sources,  in  varying  amounts,  namely:  secretion 
from  the  uterine  cavity  proper,  secretion  from  the  cervical  canal, 
epithelium  from  the  vagina,  and  secretions  from  the  vulva.  The 
secretion  from  the  uterine  cavity  is  a  clear,  transparent  fluid,  small 
in  amount,  and  having  an  alkaline  reaction  ;  that  from  the  cervical 
canal  is  tenacious,  transparent,  and  thick  like  the  white  of  an  egg. 
The  epithelium  cast  off  from  the  vagina  is  mixed  with  the  uterine 
secretions  to  form  a  milky  fluid  which  is  generally  small  in  amount. 

The  sweat  and  sebaceous  glands  of  the  vulva  make  a  secretion 
of  considerable  amount,  forming  smegma,  which  is  found  in  the 
folds  about  the  nymphse  and  under  the  prepuce.  Besides  this 
there  is  the  glairy  mucus  secreted  by  the  glands  of  Bartholin  and 
Skene. 

CHARACTER  OF  THE  DISCHARGE  IN  LEUCORRHEA 

We  will  now  consider  the  discharges  under  abnormal  conditions, 
taking  up  first  the  different  characters  of  the  discharges  and  then 
the  probable  meaning  of  the  various  discharges  occurring  in  girls 
and  women  of  different  social  conditions. 

White  Discharge.  —  It  is  white,  creamy  or  curdy,  or  viscid  and 
clear.  It  stiffens  the  linen  but  does  not  stain  it.  It  may  mean 
pelvic  congestion,  endometritis,  or  laceration  of  the  cervix,  with  or 
without  uterine  malposition. 

Yellow  Discharge.  —  It  is  light  yellow  (muco-purulent),  markedly 
yellow  (purulent),  or  greenish  yellow  (gonococcus  infection).  It 
may  mean  purulent  endometritis,  a  pelvic  abscess  discharging 
through  the  vagina,  pyometra  associated  with  cancer  of  the  cervix, 
and,  most  frequent  of  all,  gonococcus  infection  of  vagina,  cervix, 
urethra,  or  the  vulval  glands. 


144  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

Watery  Discharge. — This  is  a  clear,  colorless  fluid  that  docs  not 
stiffen  the  linen.  It  may  have  color  enough  to  stain  the  linen. 
It  may  mean  uterine  congestion,  endometritis,  intermittent  hydro- 
salpinx,  submucous  fibroids,  or  cancer  of  the  uterus,  especially 
cancer  of  the  body.  Under  watery  discharge  must  be  included 
leakage  of  urine  from  a  urinary  fistula  or  incontinence.  Here  the 
odor  of  urine  is  apparent. 

Fetid  Discharge. — Foul-smelling  discharge  may  be  purulent  or 
watery  in  character  and  results  from  necrosis  of  tissues.  It  may 
be  caused  by  a  neglected,  retained  pessary,  by  a  sloughing  sub- 
mucous  fibroid  or  polyp,  by  decomposed  products  of  conception, 
and,  most  frequent  of  all,  by  cancer  of  the  uterus,  especially  cancer 
of  the  cervix ;  the  discharge  in  the  last  case  having  a  characteristic 
odor. 

Bloody  Discharge. — A  discharge  tinged  with  blood,  occurring  dur- 
ing the  intermenstrual  period,  stains  and  stiffens  the  linen.  It 
may  be  due  to  endometritis,  laceration  of  the  cervix,  submucous 
fibroid,  polyp,  vaginitis,  or  cancer.  A  scanty  brownish  discharge 
lasting  for  several  weeks  may  indicate  a  disintegrating  uterine  decidua 
in  the  case  of  ruptured  tubal  pregnancy  (see  Chapter  XIX.,  page  353), 
or  it  may  mean  the  slow  breaking  up  of  a  blood  clot  within  the 
uterine  cavity. 

OCCURRENCE  OF  LEUCORRHEA 

Leucorrhea  in  Children. — The  immediate  cause  of  leucorrhca  in 
children  is  vulvitis.  A  white  discharge  occurs  sometimes  in  poorly 
nourished  children,  and  intestinal  worms,  dirt,  and  struma  have 
been  assigned  as  causes.  Just  how  these  are  factors,  and  why  some 
children  affected  by  them  have  leucorrhea  and  others  do  not,  has 
not  been  explained.  One  author  has  assigned  the  staphylococcus 
as  a  cause  and  others  have  found  a  large  variety  of  bacteria  in  these 
cases.  Masturbation  is  undoubtedly  a  cause  of  vulvitis  and  there- 
fore of  leucorrhea  with  a  white  discharge,  never  of  leucorrhea  with 
a  purulent  discharge.  The  practice  is  by  no  means  infrequent 
among  neurotic  children.  (Sen1  Chapter  XXVIII. ,  page  574.)  Pu- 
rulent vulvitis  is  due  to  gonococcus  infection  in  a  majority  of  cases. 
Recent  bacteriological  investigations  of  epidemics  of  this  disease 
in  institutions,  public  baths,  and  elsewhere  prove  that  the  gonococcus 


LEUCORRHEA  145 

is  present  in  nearly  all  of  the  cases  and  that  the  disease  is  most 
frequent  in  children  under  five  years  of  age.  There  occurs  rarely  in 
little  girls  a  vulvo-vaginitis  with  purulent  discharge,  perhaps  due 
to  the  staphylococcus.  Vaginitis  is  generally  associated  with 
vulvitis,  and  salpingitis  develops  in  a  certain  proportion  of  the 
cases.  The  disease  leaves  disabling  traces  not  only  in  closure  of 
the  tubes  but  also  in  the  form  of  adhesions  of  the  nympha3  to  the 
prepuce  arid  to  each  other.  (See  Chapter  XXI.,  page  394.) 

Leucorrhea  in  Virgins. — Transitory  leucorrhea  in  a  virgin  may  be 
due  to  a  pelvic  congestion.  The  discharge  under  these  conditions  is 
generally  either  white  and  curdy,  or  clear  and  viscid,  or  a  mixture 
of  the  two.  Sometimes  the  leucorrhea  if  of  the  viscid  type  is  from 
the  secretion  of  the  glands  of  Bartholin  caused  by  sexual  feelings. 
In  only  exceptional  instances  can  a  male  physician  ascertain  the 
facts  in  this  respect,  so  that  if  such  a  state  of  affairs  is  suspected 
the  patient  should  be  referred  to  a  woman  physician.  Persistent 
leucorrhea  in  a  virgin  is  due  to  pelvic  congestion  or  endometritis 
in  the  young,  or,  in  the  old,  may  be  due  to  cancer  of  the  body  of 
the  uterus  or  to  a  submiicous  fibroid.  Menorrhagia  is  generally 
an  attending  symptom.  A  local  examination  should  be  made 
because  in  this  way  only  can  an  intelligent  opinion  be  formed  of 
the  condition  of  the  uterine  organs.  After  the  examination  has 
been  made  the  state  of  the  general  health  should  receive  careful 
attention  in  the  way  of  correcting  anemia,  whether  or  not  local 
treatment  is  employed  in  conjunction  with  it. 

Leucorrhea  in  Married  Women. — In  women  who  are  accustomed 
to  sexual  intercourse  a  white  discharge  may  mean  simple  pelvic 
congestion.  This  is  not  an  unusual  condition  in  the  recently  mar- 
ried, the  congestion  of  the  pelvic  organs  being  excessive  because 
of  intemperance  in  coitus.  So  also,  a  leucorrhea  may  result  from 
habitual  incomplete  coitus,  part  of  the  discharge  coming  from  the 
uterine  cavity  and  part  from  Bartholin's  glands.  "  Whites"  are  a 
symptom  of  laceration  of  the  cervix,  erosions,  endometritis,  and 
uterine  misplacements.  A  yellow  discharge  is  found  in  the  vari- 
ous sorts  of  vaginitis  (see  Chapter  XX.,  page  361).  Vaginitis 
following  infection  during  or  after  confinement  is  very  common, 
and  also  gonorrheal  vaginitis.  The  gonorrhea!  sort  is  apt  to  date 
from  marriage  or  intercourse  and  to  be  accompanied  by  frequent 
and  smarting  micturition.  A  vulvo-vaginal  abscess  or  a  bubo  may 
10 


146  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

have  complicated  the  disease.  Parous  women  are  more  apt  to 
have  cancer  of  the  cervix  than  nullipani-.  This  disease  is  attended 
by  a  yellow  or  bloody  vaginal  discharge.  Retained  products  of 
conception  cause  a  bloody  discharge,  as  a  rule,  and  sloughing 
fibroids  or  polypi  a  foul,  purulent  discharge,  while  a  submucous 
fibroid  causes  a  thin,  watery  leucorrhea.  A  persisting  brownish 
discharge;  may  mean  extra-uterine  pregnancy. 

Leucorrhea  in  Old  Women. — Women  who  have  passed  the  meno- 
pause should  have  no  vaginal  discharge  if  their  uterine  organs  have 
atrophied  in  a  normal  manner.  If  there  is  a  white  discharge  it 
may  be  due  to  senile  endometritis,  caused  by  old-standing  uterine 
lesions.  A  yellow  or  bloody  discharge  means  either  senile  vaginitis 
or  cancer,  and  so  often  the  latter  that  no  time  should  be  lost  in 
investigating  the  condition  of  the  uterine  organs  as  soon  as  the 
symptom  is  reported. 

DYSPAREUNIA 

Dyspareunia,  from  the  Greek  doardpzwKs,  ill-mated,  is  the 
name  given  to  pain  or  difficulty  in  sexual  intercourse. 

Difficulty  in  accomplishing  the  sexual  act  may  be  due  to  (1) 
psychoneurological,  or  to  (2)  anatomical  causes.  Of  (1)  the 
psychoneurological  causes,  we  may  enumerate  repulsion  or  aversion 
on  the  part  of  the  wife.  Cases  arc  on  record  where  women  have 
refused  to  let  their  husbands  touch  them  throughout  a  long  series 
of  years  of  married  life  because  of  repulsion,  or  the  husband's 
awkward  manner  of  approach.  Another  of  the  psychoneurological 
causes  is  vayinismus  (sec  Chapter  XX.,  page  378),  a  spasmodic 
reflex  contraction  of  the  levator  ani  and  other  muscles  about  the 
vulva  excited  by  the  slightest  touch.  This  affection  may  be 
associated  with  actual  smallness  of  the  vagina  or  an  irritable  hymen, 
or  it  may  be  due  entirely  to  an  irritable  condition  of  the  nervous 
system. 

(2)  Anatomical  causes  of  both  difficult  and  painful  intercourse 
are  («)  those  situated  in  the  vulva  or  lower  vagina — a  rigid  hymen, 
a  small  vagina,  either  from  faulty  growth  or  from  cicatricial  stenosis, 
chronic  vaginitis,  urethral  caruncle,  vulvitis,  a  vulvo-vaginal 
abscess,  chancres  or  chancroids  of  the  vulva,  and  kraurosis  vulvjp; 
and  (6)  deeper-seated  conditions,  of  which  the  chief  are, — metritis, 


STERILITY  147 

lacerations  of  the  cervix  with  tender  cicatrices,  prolapsed  and 
tender  ovaries,  and  masses  of  pelvic  inflammatory  exudate.  It  is 
unnecessary  to  consider  here  the  acute  inflammations  of  vulva, 
vagina,  uterus,  ovaries  and  tubes,  or  pelvic  peritoneum  because, 
of  necessity,  intercourse  could  not  take  place  in  the  presence  of 
such  conditions. 

Disproportion  between  the  size  of  the  penis  and  the  caliber  of 
the  vagina,  or  a  deficiency  in  the  lubricating  fluids  secreted  by  the 
prostate  in  the  male  and  Bartholin's  glands  in  the  female,  may  be 
causes  of  dyspareunia. 

In  getting  a  history  of  pain  during  intercourse  the  physician  must 
inquire  whether  the  pain  is  at  the  beginning,  or  after  the  penis  has 
entered  the  vagina.  If  at  the  beginning,  the  cause  is  probably  to 
be  sought  in  vaginismus  or  in  class  (a)  of  the  anatomical  causes;  if 
after  the  penetration  of  the  male  organ  the  cause  is  in  class  (6). 
Inquiry  should  be  made  whether  the  pain  has  been  present  with 
coitus  since  the  beginning  of  married  life,  or  has  been  noted  follow- 
ing the  occurrence  of  any  of  the  symptoms  of  pelvic  disease. 

Physical  examination  will  reveal  all  of  the  anatomical  causes  and 
also  vaginismus. 

STERILITY 

Sterility,  from  the  Latin  word  sterilis,  barren,  meaning,  when 
applied  to  a  woman,  that  she  has  not  borne  a  living  child, — not  that 
she  is  unable  to, — is  classified  as  absolute  (primary]  sterility  where 
no  child  has  been  borne  and  no  miscarriage,  or  no  abortion  has 
taken  place,  as  relative  (secondary]  sterility  where  one  or  more  preg- 
nancies have  occurred,  followed  by  a  period  of  unfruitfulness,  or  fac- 
ultative sterility,  infertility  caused  by  the  prevention  of  conception. 

Sterility  may  be  due  either  to  the  husband  or  to  the  wife,  possibly 
to  both,  therefore  no  physician  should  submit  a  woman  to  local 
treatment  for  sterility  without  first  assuring  himself  that  the 
husband's  organs  of  procreation  are  functionating  normally.  This 
is  done  by  questioning,  by  an  examination  of  the  penis  and  testicles, 
and  by  a  microscopical  examination  of  semen  spent  into  a  glass 
vial,  which  is  then  corked  and  kept  warm  at  the  body  temperature, 
by  placing  it  in  warm  water.  Questioning,  not  in  the  presence  of 
the  wife,  will  determine  whether  the  man  thinks  that  coitus  is 


148  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

performed  normally,  or  whether  he  has  noticed  any  abnormality  of 
his  generative  organs,  or  has  had  gonorrhea.  Examination  of  the 
penis  and  testicles  by  the  physician  may  detect  some  anomaly  that 
the  patient  had  not  suspected: — it  may  show  a  gleety  urethra! 
discharge.  Microscopical  examination  of  the  semen  on  a  warm 
slide  will  show  whether  it  contains  living  spermatozoa  or  not. 
Care  must  be  exercised  not  to  heat  the  bottle  containing  the  semen 
too  much  or  to  let  it  get  cold,  or  the  spermatozoa  may  be  killed. 

STERILITY  ix  THE  MALE 

The  frequency  with  which  the  fault  lies  with  the  husband  in 
cases  of  sterility  is  obviously  a  matter  difficult  to  determine.  San- 
ger,  and  Lier  and  Ascher  (quoted  by  Kelly,  "Medical  Gynecology") 
have  studied  this  matter  in  a  number  of  cases.  Of  242  husbands  of 
sterile  marriages  examined  by  these  authors,  104,  or  43  per  cent, 
showed  absence  of  living  spermatozoa,  or  deficiency  of  semen  and 
impotency,  the  proportions  being,  respectively,  79  cases,  and  25 
cases.  Further,  55  of  the  men  had  infected  their  wives  with 
gonorrhea,  producing,  as  the  authors  assume,  indirect  sterility. 

A  fair  inference  from  these  statistics,  by  three  competent  observ- 
ers, is  that  in  something  over  half  of  the  sterile  marriages  the  fault 
lies  with  the  husband,  hence  the  importance  of  investigating  the 
man  as  well  as  the  woman. 

STERILITY  ix  WOMEN 

Age  as  a  Factor. — As  pointed  out  by  Matthews  Duncan  and  shown 
in  the  following  table,  the  age  at  marriage  is  the  chief  factor  in  the 
expectation  of  sterility. 

ARC  at  Marriage.  15-19      20-24      25-20      30-34      35-39      40-44      45-49 

Percentage  of   wives  bearing  a 

child -within  t\\o  Years  .  4:5.7       90. ,">       7.5.S      G2.9      40.9      1.">.4        4.3 


From  this  it  will  be  seen  that  fecundity  is  greatest  in  women 
who  have  been  married  between  the  ages  of  twenty  and  twenty-four, 
and  decreases  progressively  until  the  menopause'. 


STERILITY 


149 


Duncan  has  shown  also  by  his  statistics  that  of  the  wives  married 
between  the  ages  of  twenty  and  twenty-four  who  were  all  fertile, 
only  six  and  two-tenths  per  cent  began  to  bear  after  three  years 
of  marriage.  In  other  words,  when  the  expectation  of  fertility  is 
greatest  the  question  of  probable  sterility  is  soonest  decided. 

The  age  of  the  wife  has  a  bearing  on  sterility,  for,  according  to 
this  same  author's  statistics,  the  following  percentages  were 
observed :— 


Age  of  Wives  at 
Marriage. 

15-19 

20-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50  and 
over. 

Total. 

Number  of  wives 

observed  

700 

1,835 

1,120 

402 

205 

110 

46 

29 

4,447 

Sterile  wives  .... 

51 

0 

311 

151 

109 

100 

44 

29 

725 

Percentage  sterile 

7.3 

0 

27.7 

37.5 

53.2 

90.9 

95.6 

100 

16.3 

Other  Factors. — The  factors  essential  for  procreation,  as  far  as  the 
woman  is  concerned,  are,  the  presence  of  a  living  ovum,  a  healthy 
endometrium  upon  which  the  ovum  may  develop,  permeability  of 
the  genital  tract  so  that  the  spermatozoon  may  reach  the  ovum, 
and  secretions  of  the  genital  tract  that  are  not  inimical  to  the  life 
of  the  spermatozoon,  or  that  do  not  bar  its  upward  progress  to  the 
ovum. 

Entrance  of  the  penis  into  the  vagina  is  not  necessary  to  produce 
conception,  for  cases  are  on  record  where  pregnancy  has  occurred, 
and  women  have  come  to  labor  even,  with  an  unruptured  hymen 
which  presented  only  a  minute  opening;  therefore  deposition  of 
semen  on  the  vulva  is  all  that  is  necessary  in  some  cases.  Also, 
sexual  feeling  is  not  a  necessity,  for  women  have  conceived 
after  intercourse  while  unconscious  from  intoxication  and  other 
causes,  and  artificial  insemination  has  produced  conception.  Still, 
conception  is  more  likely  to  occur  if  the  penis  enters  the  vagina  and 
if  sexual  feelings  with  an  orgasm  are  present,  the  spermatozoa,  in 
all  probability,  finding  a  more  ready  entrance  to  the  uterine  cavity 
during  the  orgasm. 

Leaving  out  of  account  the  question  of  age,  already  considered, 
the  following  may  be  enumerated  as  causes  of  sterility  in  women: — 
(1)  Bars  to  conception  in  the  form  of  anomalies  and  diseases  of  the 
uterine  organs.  (2)  Conditions  of  the  uterine  organs  causing 
interruption  of  pregnancy  and  death  of  the  fertilized  ovum  or  fetus 


150  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

(abortion  and  extra-uterine  pregnancy),  and  (3)  Constitutional 
diseases  and  general  causes  acting  either  in  preventing  conception, 
or  in  terminating  it  after  it  has  begun. 

1.  Anomalies  and  Diseases  of  the  Uterine  Organs. — The  following 
is  a  list  of  the  pelvic   diseases  commonly  found  associated  with 
sterility,  beginning  with  the  vulva  and  ending  with  the  ovaries: — 

Imperforate  or  rigid  hymen  (preventing  penetration). 

Tumors  of  the  vulva  (preventing  penetration). 

Urethral  caruncle  (dyspareunia). 

Absence  or  atresia  of  the  vagina  (preventing  penetration). 

Yaginismus  (preventing  penetration). 

Yaginitis  (destruction  of  spermatozoa  by  discharges,  especially 
gonorrhea). 

Rupture  of  the  pelvic  floor  (allowing  semen  to  run  out). 

Inversion  of  the  vagina  with  uterine  prolapse  (preventing  in- 
semination). 

Infantile  uterus  (lack  of  normal  endometrium). 

Anteflcxion  of  the  uterus  (mechanical  obstruction,  together  with 
endometrial  discharges). 

Endometritis  and  polypi  (abnormal  endometrium  and  discharge). 

Erosions  of  the  cervix  (spermatozoa  barred,  or  killed  by  dis- 
charge). 

Lacerations  of  the  cervix  (spermatozoa  barred,  or  killed  by 
discharge). 

Cancer  of  the  cervix  and  body  (spermatozoa  barred,  or  killed 
by  discharge). 

Fibroids  of  the  uterus  (unknown  direct  cause). 

Hyperin volution  of  the  uterus  (abnormal  endometrium). 

Xodular  and  obliterating  salpingitis  (very  frequent  cause, 
especially  of  one-child  sterility.  Canal  of  tube  obstructed  by 
nodules  or  closed  by  adhesive  inflammation). 

Under-development  or  atrophy  of  the  ovaries  (oophoron  of 
ovary  affected,  so  that  healthy  ova  are  not  produced,  or  are  not 
thrown  off). 

Ovarian  tumors  (all  of  functionating  oophoron  destroyed,  or 
ova  can  not  reach  tubal  ostitim). 

Adhesions  about  the  ovaries  (same  as  ovarian  tumors). 

2.  Conditions  of  the  Uterine  Organs  thut  C'auxc  Interruption  of 
Pregnancy. — The  chief  local  causes  of  abortion  are:— 


VESTCAL  SYMPTOMS  f-  f5i  0  I 

^GU-EGE  GF  GGTECr 
Pelvic  congestion  from  excessive  coitus.      r~r-r'/r 

Endometritis  (abnormal  endome'trium). 

Retrodisplacements  of  the  uterus  (preventing  the  progressive 
enlargement  of  the  uterus). 

Lacerations  of  the  cervix  (through  endometritis  and  lack  of 
protection  of  the  ovum  or  fetus). 

Syphilis  of  the  placenta  or  decidua. 

Introduction  of  foreign  bodies,  such  as  catheters,  into  the  uterus. 

Follicular  salpingitis  (furnishing  diverticula  for  the  development 
of  extra-uterine  gestation). 

3.  Constitutional  Diseases  and  General  Causes. — The  chief  con- 
stitutional affections  that  either  cause  failure  to  conceive,  or  in- 
terrupt pregnancy  are: — 

The  acute  diseases,  especially  the  infectious  diseases,  such  as 
acute  rheumatism,  scarlatina,  and  typhoid  fever. 

Alcoholism  and  morphinism. 

Syphilis  (frequent  cause.  From  syphilis  of  placenta  and 
decidua,  or  transmitted  from  father  through  semen). 

Excessive  obesity,  occurring  rapidly. 

Anemia,  associated  with  chronic  heart  disease,  kidney  disease, 
diabetes,  or  tuberculosis. 

The  psychoses  (mental  diseases  or  sudden  nervous  shocks). 

Inbreeding  (marriage  of  cousins). 

Masturbation  (chronic  pelvic  congestion  from  conjugal  onan- 
ism,  simple  masturbation,  or  douches). 

VESICAL  SYMPTOMS 

The  chief  symptoms  of  disease  or  derangement  of  function  of  the 
urinary  organs  are: — 

(1)  Difficult,  retarded,  or  painful  urination,  dysuria. 

(2)  Too  frequent  urination,  frequent  micturition. 

(3)  Incontinence  of  urine,  enuresis. 

(4)  Retention  of  urine,  iscJiuria. 

(5)  Suppression  of  urine,  anuria. 

i.  Dysuria,  from  the  Greek  words,  8u*}  ill,  and  ou/>t^}  urine, 
signifies  an  inability  to  start  the  stream  and  to  empty  the  bladder, 
and  also  pain  attending  the  act  of  micturition.  When  the  urine 
is  passed  drop  by  drop  with  spasmodic  pain  the  condition  is  known 


152  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

as  strangury  (from  T-™?-|,  a  drop  and  «> £/>»•-*,  urine).  It  is  found 
in  cystitis,  especially  in  those  forms  of  cystitis  that  are  due  to 
poisoning  by  cantharides  or  turpentine. 

Painful  or  difficult  urination  is  a  very  common  symptom  com- 
plained of  by  women  who  suffer  with  gynecological  affections. 
Some  authors  estimate  the  number  of  such  women  who  have  vesical 
symptoms  as  high  as  one-half  of  all  the  cases  applying  to  the 
physician  for  relief.  A  greater  or  less  degree  of  dysuria  almost 
invariably  accompanies  pelvic  inflammation  and  also  gonococcus 
infection,  but  more  of  this  later. 

The  physician  will  do  well  to  rule  out  first  the  general  constitu- 
tional causes  of  dysuria.  Pain  and  burning  during  urination  may 
be  due  to  a  too  acid  or  too  concentrated  urine.  This  is  the  case  in 
patients  who  habitually  ingest  a  small  quantity  of  fluids  and  also 
in  lithcmic  women.  Sometimes  this  symptom  is  indicative  of 
acute  nephritis,  because  then  the  urine  is  concentrated.  The 
ingestion  or  absorption,  through  the  lungs  or  skin,  of  turpentine 
may  cause  dysuria,  and  in  the  same  manner  cantharides,  mustard, 
and  pepper,  when  taken  internally  or  applied  to  the  skin,  may  be 
attended  by  this  bladder  symptom. 

The  local  causes  of  dysuria,  beginning  at  the  meatus  urinarius, 
arc,  wethral  caruncle  (see  Chapter  XXIII. ,  page  453).  Here  the 
pain  may  be  so  severe  that  the  nervous  system  is  upset  and  the 
patient  becomes  melancholic.  The  pain  is  described  as  "scalding," 
"stabbing,"  "shooting/'  or  "cutting,"  and  is  felt  while  the  urine 
is  passing  over  the  caruncle  and  for  some  little  time  afterward. 
The  pain  is  apt  to  be  aggravated  during  the  menstrual  period,  and 
the  dread  of  the  pain  is  often  so  great  that  urination  is  deferred  as 
long  as  possible,  so  that  retention  may  result.  In  many  of  these 
cases  there  is  a  constant  pain  in  the  vulva  as  well  as  the  pain  which 
attends  micturition,  the  constant  pain  being  aggravated  by  walking. 

Dyspareunia  generally  accompanies  dysuria  in  these  cases,  and 
there  may  be  bleeding  on  coitus. 

Urdhritis  is  due  in  a  great  majority  of  cases  to  gonorrhea  and  is 
a  common  cause  of  dysuria.  Anything  that  increases  the  con- 
gestion of  the  pelvic  organs,  such  as  menstruation  or  pregnancy, 
exaggerates  the  inflammation  of  the  urethra,  and  therefore  increases 
the  seventy  of  the  symptom  of  difficult  or  painful  micturition. 
(See  Chapter  XXIII.,  page  4.10.) 


VESICAL  SYMPTOMS  153 

Downward  dislocation  of  the  urethra  is  a  not  infrequent  cause  of 
difficulty  in  passing  urine,  and  so  is  stricture  of  the  urethra,  one  of 
the  results  of  urethritis.  Suburethral  abscess  generally  causes 
difficulty  in  urination.  It  is  a  subacute  disease  and  is  attended  by 
pain,  fever,  dyspareunia,  and  the  intermittent  discharges  of  pus. 

The  causes  of  dysuria  that  are  situated  in  the  bladder  are: — 

(a)  Calculi  and  foreign  bodies,  which  are  usually  attended  by 
cystitis;  (6)  cystitis  in  its  various  forms  (see  Chapter  XXIV.,  page 
462) ;  and  the  (c)  new  growths  of  the  bladder,  the  most  frequent  of 
which  are  papilloma  and  cancer. 

2.  Too  Frequent  Urination. — The  time-worn  term  "  irritable 
bladder"  has  given  way  to  a  more  rational  and  more  exact  descrip- 
tion of  both  the  symptoms  and  the  pathological  conditions  present. 
To  establish  the  fact  of  too  frequent  urination,  the  physician  must 
inquire  as  to  the  patient's  habit  as  regards  emptying  the  bladder. 
Many  women  are  accustomed  to  void  urine  only  at  long  intervals 
of  time,  perhaps  once  or  twice  a  day.  Perhaps  they  ingest  very 
small  quantities  of  fluids.  Under  the  influence  of  excitement,  of 
taking  more  fluids,  or  of  cold,  the  amount  of  urine  may  be  larger, 
and  the  desire  to  pass  it  consequently  more  pressing  and  more 
frequent.  On  the  other  hand,  a  small  amount  of  fluid  taken  by 
the  mouth  and  abundant  perspiration  will  diminish  the  amount 
of  urine  secreted,  and  therefore  the  necessity  for  passing  it. 

Inquiry  into  too  frequent  urination  should  deal  with  the  custom 
of  the  individual  under  ordinary  conditions  of  health.  How  many 
times  by  day,  and  how  many  times  by  night.  Too  frequent  urina- 
tion must  be  differentiated  from  incontinence,  and  this  will  be 
taken  up  in  the  section  on  incontinence. 

Most  conditions  which  make  micturition  painful  also  cause  it 
to  be  too  frequent.  This  is  the  case  with  the  inflammations  of  the 
pelvic  organs.  Here  we  are  considering  only  the  affections  which 
are  chiefly  distinguished  by  abnormal  frequency. 

During  pregnancy  the  urethra  and  the  neck  of  the  bladder  partake 
of  the  congestion  of  all  the  pelvic  organs  at  this  time.  Why  this 
congestion  of  the  neck  of  the  bladder  is  attended  by  too  frequent 
micturition  in  some  pregnant  women  and  not  in  others  we  do  not 
know. 

The  statement  may  be  made  that,  as  a  general  rule,  micturition 
is  more  frequent  during  pregnancy,  especially  during  early  preg- 


154  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

nancy,  than  at  other  times.  Women  who  suffer  with  uterine 
disease  may  have  too  frequent  micturition  only  at  the  time  of 
menstruation  because  of  the  additional  congestion  of  the  neck  of 
the  bladder  at  that  period. 

The  ingestion  of  large  quantities  of  fluids,  especially  of  those 
which  have  a  diuretic  effect,  like  tea,  coffee,  arid  beer,  is  followed 
by  frequent  micturition,  so  also  are  diabetes  mellitus,  diabetes 
insipidus,  and  hysteria,  because;  of  the  secretion  of  an  abundant 
supply  of  urine  in  these  diseases. 

Urethritis  and  stricture  of  the  urethra  are  causes  of  frequency, — 
even  congenital  smallness  of  the  meatus  may  cause  frequency. 
Contracted  bladder,  by  not  permitting  any  considerable  quantity  of 
urine  to  accumulate,  causes  frequency,  and  so  do  tumors  of  the 
bladder  situated  in  the  neighborhood  of  the  vcsical  trigone. 

Cystitis  is  attended  by  increased  frequency  of  micturition,  in 
fact  it  is  a  cardinal  symptom,  but  there  are  no  data  in  hand  to 
show  that  increased  frequency  is  due  to  ureteral  or  kidney  disease 
where  the  bladder  is  not  at  the  same  time  affected,  although  put 
from  a  suppurating  kidney,  in  the  same  manner  as  concentrated 
urine, — perhaps  containing  crystals, — may  stimulate  the  bladder 
neck  and  cause  frequency  of  urination,  also  the  passage  of  a  renal 
calculus  along  the  ureter  may  cause  a  reflex  desire  to  urinate.  The 
bladder  is  so  frequently  involved  in  cases  of  pyelitis  and  ureteral 
calculus,  however,  that  frequency  of  urination  may  be  considered 
a  symptom  of  these  diseases. 

3.  Incontinence  of  Urine  (Enuresis}. — 1.  Local  Causes. — Inability 
to  control  the  escape  of  urine  from  the  bladder,  or  the  passing  of 
it  unconsciously,  may  be  due  first  of  all  to  an  overdistcnded  bladder. 
In  this  event  the  urine  escapes  a  little  at  a  time  and  the  patient 
may  not  realize  that  the  bladder  is  overfilled;  her  complaint  being 
only  that  her  clothes  are  wet  or  that  she  can  not  control  the  urine, 
permanent  incontinence  exists  in  vesico-vaginal  fistula,  also  in 
vesico-uterine  and  uretero-vaginal,  or  uretero-uterine  fistula.  (See 
Chapter  XXIV.,  page  474.) 

Incontinence  is  a  feature  in  epispadias,  downward  dislocation 
of  the  urethra,  and  in  some  cases  of  prolapse  of  the  uterus,  and  in 
cystocele.  In  the  latter  cases  the  urine  may  escape  only  when  the 
.intra-abdoniinal  pressure  is  increased  in  laughing,  coughing,  sneez- 
ing, or  straining. 


VESICAL  SYMPTOMS  155 

2.  General  Causes. — Nocturnal  enuresis  is  a  form  of  incontinence 
found  in  children.  Here  large  quantities  of  urine  are  voided,  quite 
unconsciously,  at  night  only,  the  affection  being  supposed  to  be 
caused  by  an  over  reflex  excitability  of  the  nervous  mechanism  of 
the  bladder.  Rarely  a  local  abnormality,  such  as  an  adherent 
prepuce,  may  act  as  a  cause. 

Incontinence  may  be  due  to  a  disorder  of  the  brain  itself  (a),  or 
(6)  to  some  affection  of  that  portion  of  the  spinal  cord  which  puts 
the  brain  into  communication  with  the  vesical  centers  in  the  sacral 
segments  of  the  cord. 

(a)  The  conditions  which  inhibit  conscious  cerebral  activity  are: 
coma,  from  whatever  cause,  as  alcohol,  epilepsy,  or  cerebral  hem- 
orrhage; some  insanities;  sunstroke;  shock,  and  the  poisons  of 
some  of  the  infectious  diseases,  as  diphtheria  and  typhoid  fever. 

(6)  The  lesions  which  interfere  with  the  conduction  between  the 
brain  and  the  vesical  centres  in  the  lower  cord  are:  myelitis, 
injuries  and  tumors  of  the  cord,  spinal  meningitis,  and  locomotor 
ataxia. 

If  the  reflexes  are  entirely  abolished  total  paralysis  of  the  bladder 
with  retention  and  dribbling  of  urine  ensues;  if  the  paralysis  is 
partial,  there  will  be  partial  retention,  with  occasional  voiding  of 
urine  and  its  involuntary  escape  after  voluntary  urination  is 
finished.  The  last  happening  is  a  frequent  occurrence  in  locomotor 
ataxia. 

4.  Retention  of  Urine  (Ischuria}. — The  urine  may  be  retained  in 
the  bladder  and  the  patient  unable  to  void  it  in  the  same  diseases 
of  the  brain  and  spinal  cord  as  in  the  case  of  incontinence  just 
noted.  It  is  a  pretty  constant  symptom  of  multiple  sclerosis. 
Retention  often  alternates  with  incontinence  in  cases  of  coma 
and  the  typhoid  state.  Retention  is  common  in  hysteria,  and  in 
order  that  overdistention  of  the  bladder  may  be  avoided,  the 
physician  should  palpate  and  percuss  the  lower  abdomen  of  the 
hysterical  woman  to  detect  a  full  bladder.  Retention  is  not  un- 
common during  late  pregnancy,  and,  whatever  the  cause,  may  result 
in  a  lack  of  expelling  power  and  atony  of  the  bladder.  Retention 
is  to  be  expected  in  incarceration  of  the  retroftexed  pregnant  uterus, 
and  may  occur,  rather  infrequently,  in  fibroids  and  ovarian  tumors. 
Retention  has  occurred  because  of  blocking  of  the  urethra  by  a 
suburethral  abscess,  or  by  cancer  of  the  urethra.  Temporary  re- 


156  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 


tontion  has  Ix'on  caused  by  tho  occluding  of  the  urethra  by  a  cal- 
culus or  a  podunculatod  tumor  of  tho  bladder,  and  lodgment  of  a 
stone  in  the-  ureter  may  produce  retention  by  causing  spasm  of  the 
sphincter  vesic;e. 

5.  Suppression  of  the  Urine  (Anuria).  —  If  urine  is  not  secreted,  or 
if  secret  oil  does  not  reach  the  bladder,  the  condition  is  known  as 
suppression  of  urine,  or  anuria.  Tho  catheter  must  be  passed  and 
the  bladder  found  empty  before  anuria  may  be  said  to  be  present. 

Anuria,  a  rare  condition,  may  occur  in  hysteria,  in  uremia,  during 
the  terminal  stage  of  chronic  nephritis,  in  acute  nephritis,  or  in 
poisoning  by  turpentine,  load,  phosphorus,  or  cantharides.  Sup- 
pression of  urine  has  boon  noted  in  yellow  fever,  typhoid  fever,  and 
the  late  stages  of  acute  yellow  atrophy  of  the  liver,  and  in  sunstroke. 

In  hysterical  anuria  the  diagnosis  is  established  by  passing  the 
catheter  and  then  repeating  the  procedure  after  a  definite  interval 
of  time,  —  say  two  hours,  when  the  patient  does  not  expect  it,  — 
thus  obviating  conscious  or  unconscious  malingering.  If  both 
ureters  are  obstructed  by  disease  within,  or  by  pressure  from  with- 
out (sec  Chapter  XXV.,  page  489),  so  that  no  urine  reaches  the 
bladder,  the  condition  is  known  as  obstructive  anuria.  This  is  a 
rare  condition,  the  diagnosis  being  made  by  cystoscopy  and  ure- 
tcral  catheterization. 

RECTAL  SYMPTOMS 

In  taking  the  history,  certain  facts  pointing  toward  rectal  disease 
are  to  be  noted;  among  them  are  the  occurrence  of  slight  morning 
diarrhea,  continuing  over  a  long  period  of  time  and  alternating  with 
attacks  of  constipation,  a  sense  of  weight  in  tho  pelvis,  dull  pain 
in  the  region  of  the  sacrum,  and  pain  or  swelling  of  the  left  lower 
limb. 

Pain.  —  As  to  pain,  ask  when  it  was  first  noticed,  the  exact  situa- 
tion, how  long  tho  attack  usually  lasts,  what  effect  has  defecation 
upon  it,  and  how  severe  it  is.  The  most  probable  cause  of  pain 
occurring  over  a  long  period  of  time  is  fissure.  When  of  recent 
occurrence,  pain  may  be  due  to  fissure,  complete  fistula,  blind 
internal  fistula,  or  prolapsed  internal  piles.  If  the  pain  is  in  the 
anus  the  chances  are  that  the  lesion  is  there,  whereas  if  it  is  in  tho 
region  of  the  sacrum  the  lesion  is  probably  in  the  rectum  proper. 


FECAL  SYMPTOMS  157 

If  the  pain  lasts  after  defecation  for  several  hours,  the  probable 
diagnosis  is  fissure  or  blind  internal  fistula,  or  complete  fistula  with 
a  large  internal  opening.  Pain  ceases  after  defecation  in  the  case 
of  stricture,  but  in  the  case  of  piles  the  pain  persists  as  long  as  the 
piles  are  outside  the  sphincter. 

Pain  following  defecation  indicates  fissure,  blind  internal  fistula, 
prolapsed  internal  piles,  or  a  protruded  polypus  or  tumor.  Pain 
accompanying  constipation  and  relieved  only  by  emptying  the 
rectum,  is  probably  due  to  impaction  of  feces,  ulceration,  or  stricture. 
Pain  or  itching,  coming  only  after  the  patient  has  gone  to  bed,  may 
mean  external  piles  or  eczema  about  the  anus. 

Hemorrhage. — Hemorrhage  from  the  rectum  is  either  (a)  associ- 
ated with  defecation,  or  (6)  it  is  independent  of  defecation. 

(a)  Bleeding  internal  piles  and  fissure  cause  loss  of  blood  with 
the  stools.  When  the  feces  passed  are  only  smeared  with  a  little 
blood,  the  diagnosis  may  be  ulcer  of  the  rectum.  Profuse  hemor- 
rhage sometimes  accompanies  defecation  in  the  case  of  internal  piles, 
a  slight  hemorrhage  being  more  usual  in  cases  of  prolapse,  polyp,  or 
villous  tumor. 

(6)  Hemorrhage  independent  of  defecation  occurs  in  some  cases 
of  internal  piles,  cancer,  and,  in  the  case  of  prolapsed  growths,  in 
prolapse  of  the  mucous  membrane,  in  internal  piles,  and  in  polyp. 
Continuous  hemorrhage  seldom  lasts  more  than  twenty-four  hours 
and,  as  a  rule,  hemorrhage  in  rectal  disease  is  intermittent.  Blood 
may  come  from  the  skin  around  the  anus  in  the  case  of  eczema, 
fissures,  external  piles,  or  tuberculosis  in  that  region. 

Rectal  Discharge. — Besides  blood,  there  may  be  discharged  from 
the  rectum,  mucus,  muco-pus,  and  serous  fluid.  An  increase  in 
the  amount  of  the  rectal  mucus  is  found  in  proctitis,  in  internal 
piles,  in  prolapse,  and  in  stricture  with  invagination  of  the  rectum. 

In  the  case  of  chronic  hypertrophic  proctitis  the  amount  of 
mucus  passed  per  anuin,  often  involuntarily,  is  so  great  that  the 
patient  is  forced  to  wear  a  napkin.  Pus  is  due  to  an  abscess  which 
has  ruptured  into  the  bowel,  or  to  a  fistula-in-ano.  Muco-pus  is 
generally  found  in  ulceration,  whether  malignant  or  simple. 

Serous  fluid  is  passed  in  cases  of  villous  tumor,  often  in  large 
quantities  and  involuntarily.  Besides  making  inquiry  on  these 
points  the  patient's  linen  should  be  inspected. 

Fecal  Accumulation. — The  rectum  is  almost  always  found  filled 


158  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

with  fcccs  iii  cases  of  fissure,  internal  piles,  eczema  of  the  anus,  and 
hypertrophy  of  the  external  sphincter  from  whatever  cause.  In 
the  case  of  stricture  of  the  rectum  the  accumulation  of  feces  will  be 
found  above  the  stricture,  not  below.  The  symptoms  of  this 
condition  may  be  nothing  more  than  a  sense  of  fulness  in  the  rectum, 
or  there  may  be  no  symptoms.  Digital  examination  makes  the 
diagnosis.  The  physician  should  have  the  probabilities  in  mind 
before  making  the  examination. 

Difficulty  in  Defecation. — AVith  this  condition  there  is  present  a 
more  or  less  constant  desire  to  empty  the  bowel,  and  defecation  is 
not  attended  by  relief.  It  is  not  the  same  as  constipation.  If  the 
dread  of  going  to  stool  is  due  to  pain  caused  by  the  act,  the  probable 
diagnosis  is  fissure,  or  ulcer,  or  a  partly  torn  off  polyp,  causing 
spasm  of  the  sphincter.  If  there  is  a  tightness  of  the  sphincter, 
the  muscle  will  be  found  hypertrophied  and  non-dilatable.  If  there 
is  much  pain  with  straining  before  and  during  defecation  and 
disappearing  entirely  after  defecation,  leaving  a  sense  of  only 
partial  relief,  a  stricture  is  probably  present. 

Character  of  the  Feces. — Diarrhea  is  not  a  true  diarrhea  unless  it 
consists  of  a  frequent  discharge  of  fecal  matter,  whether  solid,  semi- 
solid,  or  fluid.  True  diarrhea  is  not  frequently  met  with  in  rectal 
disease.  If  the  feces  are  passed  in  short  pieces  of  small  caliber,  with 
a  little  mucus  and  blood,  or  pus  and  blood,  a  stricture  is  probably 
present.  If  there  is  much  blood  and  the  feces  are  not  in  small 
pieces,  cancer  is  to  be  suspected.  In  prolapse  or  invagination  of 
the  rectum,  the  feces  are  apt  to  be  scybalous. 

Protrusion  from  the  Anus. — This  occurs  in  internal  piles,  polyp, 
and  pedunculated  tumors,  including  villous  tumors  and  cancer.  If 
the  protrusion  is  associated  with  defecation,  the  tumor  returning  to 
the  rectum  spontaneously  soon  after, — the  probable  diagnosis  is 
internal  piles,  a  polyp  with  short  pedicle,  a  moderate  degree  of 
prolapse,  or  a  villous  tumor.  When  the  protrusion  remains  down  for 
several  hours,  the  probable  diagnosis  is  internal  piles  which  have 
become  pedunculated,  a  polyp  with  long  pedicle,  a  marked  degree  of 
prolapse,  or  a  villous  tumor,  and  also,  if  protrusion  occurs  on  stand- 
ing or  straining,  it  is  probably  due  to  an  extreme  degree1  of  any  of 
these.  The  affections  referred  to  in  the  preceding  section  will  be 
found  described  at  length  in  Chapter  XX VI.,  pages  -498,  and 
.5123-525. 


COCCYGODYNIA  159 

COCCYGODYNIA 

The  term  coccygodynia  (from  •/.<'> -/.-/.u '= }  coccyx,  and  o'<Wv^  pain) 
is  the  name  given  by  Sir  James  Y.  Simpson  to  pain  in  the  region  of 
the  coccyx,  an  affection  occurring  almost  entirely  in  women  and 
generally  due  to  injury  of  the  coccyx  during  labor.  Some  time 
previous  to  May,  1844,  Dr.  J.  C.  Nott,  of  Mobile,  Alabama,  removed 
the  last  two  coccygeal  bones  in  a  young  unmarried  woman  for 
"neuralgia  of  the  coccyx,"  due  to  caries  of  the  coccyx,  following 
injury  from  a  fall.  This  is  the  first  recorded  instance  of  coccy- 
godynia, which  is  very  commonly  associated  with  gynecological 
affections. 

Coccygodynia  may  occur  in  men  when  due  to  injury,  but  it  is 
extremely  rare.  As  in  Nott's  case,  the  disease  in  woman  may  be 
.associated  with  caries  of  the  bone;  this  is,  however,  rare,  arid  the 
pathological  appearances  of  the  specimens  removed  by  operation 
show  most  often  disease  of  the  joint  between  the  first  and  second 
coccygeal  bones.  The  three  lower  bones  are  generally  ankylosed 
in  adults  so  that  forcing  them  backward, — as  in  labor, — or  forward, 
as  in  a  fall  on  the  buttocks  when  the  thighs  are  flexed,  places  the 
strain  on  the  only  movable  joint,  that  between  the  first  and  second 
pieces.  Besides  injury  to  the  joints  the  coccyx  may  be  fractured. 
The  etiology  of  the  pain  is  obscure  and  some  authors  attribute  it  to 
rheumatism  of  the  muscles  in  the  neighborhood  of  the  coccyx, 
others  to  sprains  of  the  ligaments,  and  still  others  to  some  affection 
of  Lushka's  coccygeal  gland,  which  has  a  rich  nerve  supply. 

The  symptoms  consist  of  continuous  pain  in  the  region  of  the 
coccyx  aggravated  by  sitting  down  and  by  rising  from  a  sitting 
posture.  A  hard  seat  causes  especially  severe  pain  and  pain  is 
exaggerated  by  defecation  and  by  coitus.  Mild  cases  are  fairly 
common,  but  severe  ones  are  infrequent.  In  the  bad  cases  there 
may  be  constant  pain  along  the  entire  length  of  the  spinal  column; 
the  patient  may  get  up  from  a  sitting  posture  by  placing  the  palm 
of  one  hand  upon  the  scat  of  the  chair  and  the  other  on  any  con- 
venient support,  and  pushing  the  body  up  by  the  arms  as  much  as 
possible,  so  as  to  avoid  contracting  the  muscles  of  the  pelvic  floor 
and  the  glutei.  The  bad  cases  are  usually  the  victims  of 
neurasthenia. 


160  THE  CHIEF  SYMPTOMS  OF  PELVIC  DISEASE 

Iii  making  the  diagnosis,  tenderness  of  the  coccyx  to  light  pres- 
sure, both  from  the  skin  surface  and  by  a  finger  in  the  rectum,  is  the 
chief  feature.  If  there  is  dislocation  the  lower  bones  of  the  coccyx, 
grasped  between  the  finger  in  the  rectum  and  the  thumb  in  the 
crease  of  the  nates,  may  be  thrown  out  of  line  with  the  upper  bone, 
or  bones.  A  fracture  may  be  felt  as  a  ridge  on  the  surface  of  the 
coccyx. 

Tenderness  over  the  coccyx  by  both  vaginal  and  rectal  digital 
examination  may  be  found  in  proctitis  (see  Chapter  XXVI.,  page 
506),  therefore  in  establishing  the  diagnosis  of  coccygodynia  this 
disease  must  be  ruled  out. 


PRURITUS  VULV^E 

Pruritus  vulvsc,  or  itching  of  the  vulva,  is  a  symptom  which 
may  be  the  source  of  a  great  deal  of  misery  to  its  victim,  and  may 
lead  to  serious  derangement  of  the  health  from  loss  of  sleep  and 
constant  nervous  irritation.  In  the  severe  grades  it  is  often  accom- 
panied by  evidences  of  impairment  of  the  nervous  system,  such  as 
frequency  of  micturition,  indigestion,  irritability  of  temper,  and 
instability  of  disposition.  It  is  a  symptom  and  is  undoubtedly 
due  to  a  certain  sort  of  irritation  of  the  terminal  filaments  of  the 
nerves  in  the  skin  of  the  vulva,  but  the  pathology  is,  as  yet,  unknown. 
The  causes  of  pruritus  may  be  divided  into:  (1)  irritating  dis- 
charges from  the  vagina  or  bladder,  (2)  diseases  of  the  vulva,  and 
(3)  neuroses. 

i.  Irritating  discharges  from  the  vagina  are,  (a)  leucorrhea  from 
chronic  endometritis.  Leopold  holds  that  this  is  a  very  common 
cause  of  pruritus;  also  leucorrhea  from  vaginitis,  as  in  gonorrhea, 
is  a  not  uncommon  cause  of  itching. 

(7>)  The  urine  of  diabetes  is  a  frequent  cause  of  pruritus.  The 
patient  complains  of  great  thirst,  drinks  large  quantities  of  water, 
and  is  hungry  most  of  the  time.  Examination  of  the  vulva  shows 
slight  redness  about  the  orifice  of  the  urethra,  redness  and  perhaps 
induration  of  the  labia,  and  excoriations  from  scratching.  The 
urine  lias  a  sweetish  smell  and  on  examination  is  found  to  contain 
sugar.  Pruritus  is  often  the  first  symptom  which  leads  to  the 
diagnosis  of  diabetes. 


PRURITUS   VULV.E  161 

(c)  The  urine  of  cystitis,  or  nephritis,  may  cause  pruritus,  but 
this  is  not  a  common  happening  and  usually  yields  readily  to  treat- 
ment for  the  urinary  difficulty. 

2.  Diseases  of  the  vulva  causing  pruritus  are,  first,  (a)  congestion 
of  the  vulva  and  varix  of  the  vulva,  both  commonly  found  in  preg- 
nancy, in  uterine  or  ovarian  tumors,  or  in  any  obstruction  to  the 
venous  return  of  the  blood  in  the  pelvis,- — such  as  intra-abdominal 
pressure  on  the  vena  cava.     Even  the  congestion  of  the  menstrual 
period  may  be  accompanied  by  itching. 

(6)  Vulvitis  and  kraurosis  vulva?  are  attended  by  more  or  less 
pruritus,  the  latter,  generally  by  intense  itching. 

(c)  Pediculus  pubis  is  a  cause  of  itching.     On  careful  inspection 
of  the  hairs  of  the  vulva  the  parasites  or  their  nits  are  readily  seen 
and  are  destroyed  by  shaving  the  parts  and  anointing  with  a  ten- 
per-cent  solution  of  carbolic  acid  and  olive  oil. 

(d)  Thrush  of  the  vulva  is  a  cause  of  pruritus,  and  in  little  girls 
(e)  simple  uncleanliness  seems  to  operate  as  a  cause.     (/)  Eczema 
of  the  vulva  is  nearly  always  attended  by  severe  itching. 

3.  Neuroses. — Under  this  head  we  may  include,  (a)  masturba- 
tion, although  it  is  doubtful  whether  the  itching  is  not  the  cause  of 
the  masturbation,  rather  than  the  reverse.     There  can  be  no  doubt, 
however,  but  that  constant  handling  and  irritation  of  the  clitoris 
and  vulva  make  for  hypersensitiveness  and  therefore  exaggeration 
of  a  predisposition  to  pruritus. 

(6)  Oxyuris  vermicularis,  or  pin-worms,  found  in  the  rectum  in 
children,  cause  itching  not  only  about  the  anus  but  of  the  vulva 
also.  In  pruritus  vulva?  in  a  child  this  cause,  as  well  as  uncleanli- 
ness, should  be  always  sought  for. 

(c)  Pruritus  is  common  at  the  menopause  without  discoverable 
lesions  of  the  vulva,  and  is  observed  sometimes  also  in  (d)  women 
having  a  rheumatic  diathesis. 


11 


PART  II 

SPECIAL  DIAGNOSIS 


THE   DIAGNOSIS   OF   ENDOMETRITIS,    INCLUDING 

GONORRHEA   AND   EROSIONS   OF   THE 

CERVIX   UTERI 

Anatomy  and  physiology  of  the  endometrium,  p.  166. 

Pathology,  p.  169. 

Anatomico-pathological  classification,  p.  170. 

Endometritis  from  a  clinical  point  of  view,  p.  173:  Acute  non-gonorrheal 
endometritis,  p.  173;  Etiology,  p.  173;  Symptoms,  p.  174;  Signs,  p.  176. 
Chronic  non-gonorrheal  endometritis,  p.  176;  Varieties,  p.  176,  (1)  Of 
puerperal  origin,  or  post-abortum,  p.  176,  (2)  Those  varieties  which  are  not 
preceded  by  a  known  acute  stage,  p.  177;  Etiology,  p.  177;  Symptoms, 
p.  177;  Signs,  p.  178.  Gonorrheal  endometritis  and  gonococcus  infection, 
p.  179.  Acute  gonorrheal  endometritis,  acute  gonorrheal  endocervicitis,  p. 
180;  Symptoms,  p.  181,  Diagnosis,  p.  181,  Differential  diagnosis,  p.  181; 
Chronic  gonorrheal  endometritis,  p.  182:  Latent  gonorrhea  in  women, 
p.  182;  Differential  diagnosis  of  chronic  gonorrheal  endometritis,  p.  183. 
Senile  endometritis,  p.  183.  Endocervicitis,  p.  184.  Erosions  of  the  cervix 
uteri,  p.  184:  Characteristics,  p.  184;  Diagnosis,  p.  185;  Differential 
diagnosis,  p.  186. 

ALTHOUGH  endometritis  is  a  part  of  the  inflammatory  process 
called  Pelvic  Inflammation,  it  may  exist  without  involvement  of 
the  periuterine  structures.  As  pelvic  inflammation  is  most  often 
caused  by  infection  introduced  through  the  vagina  and  uterus,  so 
endometritis  is  generally  a  beginning  stage  of  pelvic  inflammation. 
The  term  endometritis  will  be  used  to  define  inflammation  of  the 
endometrium. 

Endocervicitis  is  the  name  given  to  the  inflammatory  process 
when  it  is  limited  to  the  cervix.  The  differentiation  of  endocer- 
vicitis from  endometritis  of  the  body  has  a  practical  importance 
in  the  acute  infections,  especially  in  gonococcus  infection,  and 
also  in  the  chronic  form  of  inflammation  where  the  disease  is  apt 
to  be  situated  chiefly  in  the  cervical  canal.  An  inflammatory 
process  situated  in  the  endometrium  may  extend  to  the  muscular 
structure  of  the  uterus,  and  then  the  process  may  be  defined  more 
exactly  as  a  metritis. 

In  practice  the   diagnosis  of    metritis  aside  from  endometritis 

165 


166 


THE  DIAGNOSIS  OF  ENDOMETRITIS 


is  an  academic  affair  and  of  no  practical  significance  even  when 
it  is  possible  to  diagnose  OIK;  without  the  other;  therefore,  little 
will  be  wud  of  nietritis,  with  the  understanding  that  in  the  severe 
grades  of  endometritis  there  is  present  also  metritis. 


ANATOMY   AND    PHYSIOLOGY   OF   THE   ENDOMETRIUM 

A  word  as  to  the  anatomy  and  physiology  of  the  endometrium 
before  taking  up  the  consideration  of  the  different  manifestations 
of  inflammation.  The  following  description  applies  to  the  un- 
impregnated  uterus  of  the  healthy  adult  woman  between  menstrual 
periods.  It  will  be  noted  that  the  mucosa  of  the  cervical  canal 
is  anatomically  and  physiologically  different  from  the  mucosa  of 

the  uterine  cavity  proper,  therefore 
we  are  justified  in  considering  the 
word  endometrium  as  applying  to 
the  latter  only. 

The  interior  of  the  uterus  is 
divided  into  two  cavities:  the  cavity 
of  the  body,  and  the  cavity  of  the 
neck,  which  arc  separated  from  each 
other  by  the  constricting  ring  of 
muscular  tissue  about  the  internal 
os.  The  shape  of  these  cavities  has 
been  referred  to  elsewhere,  the  cav- 
ity of  the  body  being  represented  by 
an  inverted  isosceles  triangle  with 
the  two  angles  of  the  base  in  the 

uterine  comua  and  the  third  angle 
ftt  ^  ^^  ^  Thc  antcrior 

and  posterior  walls  of  the  uterus 
meet  at  the  sides  at  an  acute  angle  so  that  there  are  no  lateral 
walls  proper,  therefore  the  uterine  cavity  is  flattened  from  before 
backward.  The  cervical  cavity  is  fusiform  in  shape,  largest  in 
the  middle  and  contracted  at  the  internal  and  external  ora. 

Under  resting  conditions  the  cavity  of  the  body  is  closed  against 
infection  from  below  at  the  internal  os  and  from  infection  from 
above  bythemuscular  constrictions  at  the  isthmuses  of  the  Fallopian 
tubes.  The  cavity  of  the  cervix  in  like  manner  is  protected  from 


FIG.  64.  —  Reconstruction  of 
Uterus,  Showing  shape  of  Uterine 
Cavity  and  Cervical  Canal.  (Wil- 
hams.) 


ANATOMY  AND  PHYSIOLOGY 


167 


infection  from  above  by  the  narrowing  at  the  internal  os,  and  from 
below  in  the  nulliparous  uterus  more,  and  in  the  parous  uterus 
less,  by  the  constriction  at  the  external  os. 

The  wall  of  the  uterus  is  made  up  of  three  layers,  the  thin,  serous, 
peritoneal  layer,  the  thick  muscular  layer — composing  most  of 
the  structure  of  the  uterus — and  the  medium  thick  mucous  layer. 
The  mucous  layer,  the  endometrium,  consists  of  the  utricular 
glands,  connective  tissue,  blood-vessels,  nerves,  and  lymphatics.  It 
is  covered  by  a  single  layer  of  ciliated  columnar  epithelium — which 
also  lines  the  glands — and  is  continued  through  the  Fallopian  tubes. 


FIG.  65.  —  Normal  Endometrium.     (Williams.) 


The  endometrium  is  essentially  a  glandular  structure.  The 
glands  are  tubular  and  branching,  several  opening  often  by  one 
mouth.  They  extend  into  the  muscular  layer  and  all  open  into  the 
uterine  cavity.  In  the  body  of  the  uterus  the  endometrium  is 
closely  united  to  the  muscularis,  whereas  in  the  neck  it  is  freer. 
In  the  cervix  uteri  the  lining  epithelium  shades  into  pavement 
epithelium  at  the  external  os.  In  this  cavity  the  mucous  mem- 
brane is  thrown  into  oblique  ridges  which  diverge  from  an  anterior 
and  posterior  longitudinal  raphe,  presenting  an  appearance  which 
has  received  the  name  of  arbor  vitie. 


168  THE  DIAGNOSIS  OF  ENDOMETRITIS 

The  normal  secretion  of  the  uterine  glands  is  a  clear,  watery 
fluid,  having  an  alkaline  reaction,  that  of  the  glands  of  the  neck  is 
clear  and  viscid;  it  is  also  alkaline.  Throughout  the  cervical 
mucosa  are  found  a  variable  number  of  little  cysts,  presumably 
glands,  which  have  become  occluded  and  distended  with  retained 
secretion.  They  arc  called  the  ovula  Nabothi,  or  Nabothian 
follicles. 

The  endometrium  shows  normally  many  differences  in  structure 
from  infancy  to  old  age  and  during  theintermenstrual  and  menstrual 
cycles. 

Before  puberty  it  is  relatively  thin  and  undeveloped,  nearly  all 
of  it  having  the  character  of  the  cervical  mucosa. 

Our  views  as  regards  the  normal  histology  of  the  endometrium 
have  of  recent  years  undergone  a  considerable  change,  due  to  the 

important  observations  of  Hitschmann  and 
Adler  (Monatsschrift  fiir  Geburts.  und 
Gynaekol,  1908,  XXVII.,  1),  confirmed 
by  several  subsequent  investigators. 

Hitschmann  and  Adler,  after  a  painstak- 
ing study  of  the  uterine  mucosa  from  fifty- 
eight  women  at  various  periods  of  the 
menstrual  cycle,  found  that  the  endome- 

FIG.  66. — Virginal  Exter- 
nal Os.  (Williams.)         trium  from  the  cessation  of  one  menstrual 

flow  to  that  of  the  next,  presents  a  con- 
stantly changing  histological  picture.  This  cycle  of  changes  they 
divide  into  four  phases;  postmenstrual,  interval,  premenstrual, 
and  menstrual.  At  the  height  of  the  menstrual  flow  the  mucous 
membrane  diminishes  in  thickness  and  the  glands  pour  out  their 
secretion,  becoming  narrow  and  straight.  The  surface  epithelium 
is  frequently  lost,  but  this  is  not  an  invariable  rule.  After  the 
period  there  takes  place  a  very  rapid  cell  growth  in  both  the 
epithelium  and  connective1  tissue.  The  glands  become  larger  and 
wider,  although  still  quite  narrow  and  straight.  The  epithelium 
is  low  and  in  a  condition  of  rest.  By  about  the  fifteenth  day  the 
cell  growth  of  the  epithelium  has  progressed  to  such  an  extent  that 
the  glands  become  somewhat  tortuous,  and  often  assume  a  spiral 
or  corkscrew-like  appearance.  Finally,  six  or  seven  days  before 
the  beginning  of  menstruation,  the  glands  rapidly  enlarge  and 
become  tortuous,  the  cells  bulge1  into  the  lumen,  the  epithelium 


PATHOLOGY  169 

becomes   higher  and   broader,   and   the  lumen   is   filled   with   a 

mucous  secretion.     These  gland  changes  are  much  more  marked 

in  the  deeper  portion  of  the  mucosa  than  in  the  superficial,  so  that 

there  is  produced  a  well-marked  differentiation  into  a  superficial 

compact  and  a  deep  spongy  layer.     In  this 

respect  there   is  a  marked   similarity  to 

the  appearance  of  the  young  decidua,  the 

resemblance   being  increased  by  the  fact 

that    the  interglandular    stromal  cells  in 

many  cases  assume  an   appearance  very 

similar  to  or  approaching  that  of  decidual 

cells 

FIG.  66a. — Parous  Exter- 
During  pregnancy  the  mucosa  of  the  cor-         nai  QS.    (Williams.) 

pus  uteri   is  enormously   congested.      Its 

function  is  the  formation  of  the  decidua — the  connective-tissue 

cells  of  the    endometrium  going  to  make  the  decidual  cells   of 

pregnancy. 

Following  the  menopause  there  is  an  atrophy  of  the  endometrium 
coincident  with  the  shrinking  of  the  uterus  so  that  in  the  old 
woman  the  uterine  glands  are  found  almost  entirely  obliterated, 
and  there  is  apt  to  be  partial  or  complete  closure  of  the  uterine 
canal  at  the  internal  os. 

PATHOLOGY 

It  is  probable  that  all  forms  of  endometritis  are  due  to  bacterial 
invasion  of  the  endometrium.  The  endometrium  under  normal 
conditions  is  sterile,  and  bacteria  in  small  numbers  introduced 
from  without  are  promptly  destroyed.  Although  chemical  irrita- 
tion and  trauma  may  cause  congestion  and  favor  bacterial  growth, 
the  idea  that  these  influences  and  " constitutional  taints"  do  any- 
thing more  than  provide  a  fertile  soil  for  the  microorganisms  has 
gone  the  way  of  many  older  theories. 

The  following  bacteria  have  been  found  in  the  endometrium  in 
cases  of  endometritis— seldom  in  pure  cultures,  generally  in  mixed 
infections: — 

Staphylococcus  pyogenes  albus,  citreus,  and  aureus. 

Streptococcus  pyogenes. 

Gonococcus. 


170  THE  DIAGNOSIS  OF  ENDOMETRITIS 

Colon  bacillus. 

Tubercle  bacillus. 

Diphtheria  bacillus. 

Typhoid  baccillus. 

Pncumococcus. 

Bacillus  aerogenes  capsulatus. 

Spirochscta  pallida  of  syphilis. 

In  many  forms  of  emlonietritis  the  bacterium  reaches  the  endo- 
mctrium  from  without  by  way  of  the  vagina;  in  a  smaller  number 
of  varieties  it  comes  from  the  Fallopian  tubes  or  abdominal  cavity 
through  the  lumen  of  the  tubes;  and  in  still  other  varieties  it  comes 
through  the  lymphatics  and  veins  of  the  uterine  wall  from  near-by 
sources  of  infection  in  peritoneum,  rectum,  or  bladder;  and  rarely 
it  reaches  the  endometrium  from  distant  sources  through  the  blood 
current. 

The  classification  of  endometritis  has  long  been  a  stumbling 
block  to  the  gynecologist.  A  recent  writer  on  the  subject  gives  a 
pathological  classification  containing  eleven  different  forms,  accord- 
ing to  the  macroscopic  or  microscopic  appearances  of  the  different 
varieties,  and  a  clinical  classification  of  ten  different  sorts  of  chronic 
endometritis. 

A  bacteriological  classification  will  ultimately  be  the  one  chosen 
as  a  guide  to  diagnosis.  At  present,  not  enough  facts  are  known 
to  justify  its  use.  As  it  is  impossible  to  diagnose  the  different 
varieties  according  to  the  pathology,  except  by  examination  of 
scrapings  from  the  endometrium,  and,  according  to  the  present  state 
of  our  knowledge  of  the  pathology  of  the;  endometrium,  the  differ- 
entiation of  the  varieties  has  no  bearing  on  the  treatment,  we  shall 
consider  the  subject  from  the  clinical  point  of  view.  Suffice  to 
mention  the  forms  of  endometritis  which  have  been  recognized  as 
a  result  of  the  microscopic  examination  of  scrapings  and  of  uteri 
removed  by  operation. 

ANATOMICO-PATHOLOGICAL   CLASSIFICATION 

Hypertrophic  endometritis,  in  which  the  endometrium  is  thickened 
and  soft.  If  the  glands  are  increased  in  size  only,  it  is  called 
hypertrophic  glandular  endometriiis,  if  they  are  increased  in  number 
it  is  called  hyperplastic  ylandular  cndotuetrilis. 


ANATOMICO-PATHOLOGICAL  CLASSIFICATION 


171 


F.  Hitschmann  and  L.  Adler  (Zeit.  f.  Gebs.  u.  Gyn.,  1907,  LX., 
63)  state  that  endometritis  glandularis  hypertrophica  and  endo- 
metritis  glandularis  hyperplastica  have  nothing  whatsoever  to  do 
with  inflammation.  The  first  is  not  even  a  pathological  condition  of 
the  uterine  mucosa  but  corresponds  to  the  premenstrual  state  of  the 
normal  lining  of  the  uterus ;  the  latter  consists  partly  of  the  normal 
premenstrual  condition,  and  partly  of  variations  in  the  number  of 
glands  within  physiological  limits;  in  addition  it  includes  cases  in 
which  there  is  a  glandular  hypertrophy  of  the  uterine  mucous 
membrane,  but  this  also  is  a  change  which  is  entirely  independent  of 
inflammation. 

There  is,  according  to  these  investigators,  but  one  variety  of 
inflammation  of  the  uterine  mucosa,  endometritis  interstitialis,  or, 
as  it   is   usually   called,  en- 
dometritis.     The    diagnosis 
is   made   by  demonstrating 
the  cells  of  infiltration,  so- 
called  plasma  cells. 

If  the  inflammatory  proc- 
ess affects  chiefly  the  inter- 
glandular  connective  tissue 
the  process  is  known  as  in- 
terstitial endometritis.  This 
form  has  an  acute  and  a 
chronic  stage,  the  acute 
being  characterized  by  dif- 
fuse or  circumscribed  infil- 
tration of  the  stroma  by  small  round  cells  with  congestion  of  the 
blood-vessels  and  a  serous  exudate  in  the  spaces  of  the  connective 
tissue  (exudative  interstitial  endometritis).  The  chronic  stage  is 
characterized  by  newly  formed  connective  tissue  resulting  in  com- 
pression of  tin1  utricular  glands,  and,  in  the  later  stages  in  atrophy 
of  the  endometrium,  the  so-called  atrophic  endometritis. 

Retention  cysts  may  be  formed  in  the  interglandular  spaces  of  the 
connective  tissue  and  r//>7/r  interstitial  endometritis  results,  or  the 
glands  may  be  obstructed  by  the  pressure  of  the  connective  tissue 
at  their  mouths,  cystic  <jlandular  endometritis.  Fungous  endome- 
triti*  is  the  term  applied  when  the  mucosa  is  thrown  into  folds; 
villon*  cndonictritl^,  when  it  is  covered  with  shaggy  villosities;  and 


FIG.    67. — Horizontal  Section    of   the  Up- 
per Part  of  the  Body  of  the  Uterus. 


172 


THE  DIAGNOSIS  OF  EXDOMETRITIS 


polypoid  endometritis,  when  one  or  more  mucous  polyps  arc 
present.  When  a  layer  of  necrotic  tissue,  composed  of  degenerated 
epithelium,  blood,  leucocytes,  microorganisms,  and  fibrin  is  found 
on  the  surface  of  the  endometrium — as  in  certain  infections  follow- 
ing labor  and  abortion — the  condition  is  known  as  pseudodiph- 
theritic  endometritis.  and  when  true  ulcers  form  in  the  endome- 


Fio.  68. — Transverse  Longitudinal  Section  of  the  Uterus. 

trium — as  in  carcinoma  and  tuberculosis — the  process  is  called 
ulcerative  endometritis. 

Decidual  endometritis  is  the  name  given  to  inflammation  of  the 
endometrium  during  pregnancy.  It  is  diagnosed  definitely  by 
microscopic  examination  of  the  decidua  after  expulsion  of  the  fetus. 
Evidences  of  inflammatory  action  are  present.  The  symptoms 
may  be  hydrorrhea  uteri  gravidi,  or  pains  in  the  uterine  region 
during  pregnancy. 

A  rare  condition  is  exfoliatire  endometritis,  so-called  membranous 
dysmenoirhea.  It  consists  of  the  discharge  from  the  uterus  of  a 


ACUTE  NON-GONORRHEAL  ENDOMETRITIS  173 

more  or  less  incomplete  cast  of  the  cavity  of  the  corpus  uteri,  in 
the  shape  of  a  sac,  triangular  in  form,  gray  in  color,  and  of  a  rough 
surface.  Floated  in  water  and  laid  open,  its  interior  is  smooth. 
When  examined  under  a  magnifying  glass  it  is  seen  to  be  studded 
with  minute  openings  which  represent  the  mouths  of  the  utricular 
glands.  When  the  sac  is  reasonably  complete  the  openings  of  the 
Fallopian  tubes  may  be  distinguished  at  the  upper  angles  of  the 
sac.  The  membrane  is  from  one  to  three  millimeters  thick  and 
under  the  microscope  shows  much  the  appearances  of  exudative 
interstitial  endometritis,  although  the  pathological  appearances  vary 
in  different  cases. 

Tuberculous  endometritis,  relatively  rare,  is  a  sequel  often  of 
primary  tuberculosis  of  the  tubes.  Rarely  it  is  primary  in  the 
cervix.  Tuberculous  infection  may  reach  the  endometrium  also 
from  without  by  coitus,  or  by  instrumental  or  digital  interference. 
Occurring  in  the  late  stages  of  general  tuberculous  infection  of  the 
genito-urinary  system,  it  has  no  clinical  importance,  because  the 
other  manifestations  of  the  disease  are  of  overshadowing  seriousness. 
It  is  characterized  by  the  presence  of  giant  cells,  tubercles,  and 
tubercle  bacilli  found  microscopically  in  scrapings  made  from  the 
endometrium.  The  tubercle  bacilli  may  be  detected  in  the  uterine 
discharges.  Many  cover-slip  preparations  should  be  studied  before 
affirming  the  absence  of  the  bacillus. 

Not  much  is  knowTi  of  the  forms  of  endometritis  occurring  after 
the  acute  infectious  diseases — typhoid  fever,  diphtheria,  scarlet 
fever,  measles,  and  smallpox — nor  of  the  endometritis  which 
attends  syphilis. 

Gonorrheal  endometritis  will  be  considered  separately  under  the 
clinical  classification. 

ENDOMETRITIS  FROM  A  CLINICAL  POINT  OF  VIEW 

The  subject  is  best  divided  into  acute  and  chronic  endometritis, 
with  special  consideration  of  gonorrheal  endometritis,  senile  endome- 
tritis, and  endocervicitis. 

ACUTE  NON-GONORRHEAL  ENDOMETRITIS 

Etiology. —This  is  an  inflammation  due  to  invasion  of  the 
endometrium  by  septic  microorganisms,  more  especially  the 
staphylococcus  and  the  streptococcus.  It  is  a  grave  form  of  en- 


174  THE  DIAGNOSIS  OF  ENDOMETRITIS 

dometritis  as  contrasted  with  a  majority  of  the  chronic  forms  of  en- 
dometritis,  which  are  of  a  mild  type  and  have  no  recognizable 
acute  stage. 

Its  chief  causes  are:  (1)  infection  following  labor  and  abortion; 
(2)  the  use  of  uncleanly  fingers  or  instruments  in  making  office 
treatments;  (3)  operations  which  are  not  aseptic,  and  (4)  sloughing 
iiitra-uterine  tumors. 

(1)  Infection  following  labor  and  abortion  is  the  most  frequent 
cause  of  acute  endometritis.     It  can  not  be  entirely  avoided  even 
with  the  most   scrupulous  can1.     Retained  membranes  may  de- 
compose and  cause  it.     Too  often  the  physician  is  to  blame. 

Bacteria  brought  to  the  vagina  on  carelessly  washed  hands,  lack 
of  thoroughness  in  the  preparations  for  the  immediate  repair  of 
the  injuries  of  the  pelvic  floor  and  perineum  following  labor,  the 
unnecessary  use  of  forceps,  or  too  frequent  vaginal  examinations, 
to  say  nothing  of  too  much  douching — thereby  washing  away 
the  normal  secretions  of  the  vagina,  which,  according  to  Doder- 
lein  destroy  pathogenic  bacteria — all  play  an  important  part. 
The  great  danger  of  so-called  septic  endometritis,  which  attends 
criminal  abortion,  is  too  well  known  to  require  extended  comment. 

(2)  The  general  practitioner  of  medicine,  realizing  the  necessity 
of  washing  his  hands  after  an  examination,  is  careless  about  washing 
them  before  making  a  vaginal  examination  or  instrumental  treat- 
ment.    The  practice  of  making  intra-uterine  office  treatments  is 
dangerous   even  with    strict  asepsis,   besides  being    useless  as  a 
therapeutic  measure.     Passing  the  sound  into  the  uterine  cavity 
should  be  done  only  under  strict  aseptic  precautions  and  with  the 
utmost  gentleness  to  avoid  trauma. 

(3)  Minor  operations  may  cause  as  great  harm  as  major  ones  and 
too  commonly  do  so  because  the  preparations  for  the  lesser  pro- 
cedures are  not  as  carefully  made. 

(4)  Sloughing  of  a  uterine  polyp,  of  a  pedunculated  submucous 
fibroid,  or  of  an  inverted  uterus  sometimes  results  in  septic  endo- 
metritis unless  prompt  operative  measures  are  instituted. 

Symptoms. — The  symptoms  of  acute  endometritis  with  septic 
absorption,  acute  xcptic  endomctriti*,  manifest  themselves  within 
twenty-four  to  forty-eight  hours  after  infection,  although  they  may 
be  delayed  for  several  days.  Their  severity  depends  upon  the  form 
of  infection.  A  septic  intoxication  which  is  due  to  the  absorption 


ACUTE  NON-GONORRHEAL  ENDOMETRITIS  175 

into  the  system  of  ptomaines, — the  product  of  decomposition  set 
up  by  bacteria, — is  called  sapremia;  that  which  is  due  to  the 
absorption  of  the  bacteria  themselves  with  their  toxins  is  known  as 
septicemia  proper.  As  yet  we  have  no  means  of  determining  which 
form  of  infection  is  present  in  any  given  case.  We  know  that  the 
form  caused  by  the  streptococcus  is  the  more  grave,  that  the 
streptococcus  may  be  diffused  very  rapidly  throughout  the  system, 
and  that  in  death  resulting  from  this  form  there  may  be  found  few 
pathological  changes  in  the  pelvic  organs.  The  staphylococcus,  on 
the  other  hand,  is  more  apt  to  produce  marked  local  reaction  and 
pus  formation.  The  severity  of  the  symptoms  will  vary  according 
to  the  continued  presence  of  the  source  of  infection  and  the  rapidity 
of  its  absorption.  Although  the  endometrium  is  the  point  of  en- 
trance of  the  infective  material  into  the  system  and  endometritis 
is  the  first  manifestation  of  the  poisoning,  the  disease  is  a  general 
one  almost  from  the  first.  In  the  later  stages  of  the  disease  the 
involvement  of  tissues  neighboring  to  the  endometrium — the  uterine 
muscle,  pelvic  cellular  tissue,  the  Fallopian  tubes,  and  peritoneum — 
produces  complications  which  overshadow  the  endometritis.  The 
symptoms  are  ushered  in  by  a  severe  chill,  followed  by  elevation 
of  temperature  (103°-104°  F.  or  higher),  and  a  rapid  pulse  (110- 
120  or  higher).  If  the  disease  follows  labor  or  abortion  the  lochial 
discharge  is  diminished  in  amount  at  first  and  then  increased,  be- 
comes dark  in  color,  then  purulent,  and  generally,  though  not  in  the 
streptococcic  form,  has  an  offensive  odor.  If  the  disease  does  not 
follow  labor  or  abortion  a  bloody,  purulent,  usually  offensive  uterine 
discharge  is  a  constant  symptom  after  the  initial  chill.  Intermittent 
uterine  pains — becoming  continuous  and  severe  if  the  inflammatory 
process  reaches  the  peritoneum — nausea,  constipation,  and  frequent 
and  painful  micturition  are  early  symptoms. 

Irregularly  recurring  chills,  high  temperature,  rapid  and  feeble 
pulse,  a  sense  of  well-being  and  apathy,  the  characteristic  un- 
described  odor  of  sepsis,  diarrhea,  and  failing  strength,  are  symptoms 
of  the  advanced  stages  of  the  disease. 

Acute  endometritis  without  sapremia  or  septicemia,  is  attended  by 
comparatively  slight  constitutional  disturbances  and  the  symptoms 
arc  limited  to  elevation  of  temperature — generally  preceded  by  a 
chill — pain  of  moderate  severity  in  the  lower  abdomen,  frequent 
and  painful  micturition,  nausea,  and  disturbance  of  menstruation,, — 


170  THE  DIAGNOSIS  OF  ENDOMETRITIS 

either  suppression  or  menorrhagia.  The  symptoms  abate  in  a  few 
days. 

Signs.— In  all  forms  we  find  on  physical  examination, — the  uterus 
enlarged  and  soft,  tender  to  light  pressure  in  all  parts;  the  vagina 
hot  and  dry;  the  uterine  discharge  wanting  at  first  and  later 
increased  in  amount.  The  os  is  patulous.  Rigidity  and  tenderness 
of  the  abdominal  muscles,  called  peritonismus,  is  to  be  expected 
if  the  peritoneum  is  involved  in  the  inflammatory  process,  other- 
wise not.  Acute  endometritis  without  complications  is  uncommon. 

If  the  case  is  seen  early  an  anesthetic  should  be  given  because  of 
the  great  pain  caused  by  manipulation.  Thorough  aseptic  precau- 
tions are  observed.  A  sound  is  passed  into  the  uterus  and  retained 
membranes,  or  sloughing  tumors,  polypi,  or  fungosities  are  detected 
by  sound-touch.  In  cases  of  doubt  the  cervix  should  be  dilated 
until  it  will  admit  the  operator's  finger,  and  the  interior  of  the  uterus 
explored  by  touch,  all  adventitious  tissue  being  removed  either 
with  the  finger,  curette,  or  curette  forceps,  and  preserved  in  a  ten- 
per-cent  formalin  solution  for  microscopic  examination. 

CHRONIC  NON-GONORRHEAL  ENDOMETRITIS 

Varieties. — Chronic  endometritis  may  be  divided  into:  (1)  those 
forms  of  acute  endometritis  that  have  terminated  in  a  chronic  form, 
and  (2)  the  varieties  which  present  no  acute  stage  demonstrable 
by  clinical  methods. 

(1)  The  forms  of  acute  endometritis  which  have  become  chronic  are 
commonly  of  puerperal  origin,  or  post-abortum.  Some  of  the 
pathological  varieties  are, — pseudodiphtheritic,  decidual,  and 
ulcerative  endometritis.  A  chronic  endometritis  resulting  from 
an  acute  septic  endometritis  generally  has  as  complications  one  or 
more  of  the  following  affections: — metritis,  cellulitis,  peritonitis, 
pelvic  abscess,  or  salpingitis.  When  the  inflammatory  process  is 
centered  chiefly  in  one  of  the  situations  just  enumerated,  the  in- 
flammation of  the  endometrium  is  less  active  and  the  physical  signs 
indicate;  that  in  the  endometrium  the  fire  has,  as  it  were,  burned 
out,  leaving  only  smouldering  embers.  Microscopic  examination  of 
the  endometrium  reveals  one  or  more  of  the  different  stages  of 
glandular  and  interstitial  endometritis  as  described  on  pages  170 
and  171. 


CHRONIC   NON-GONORRHEAL  ENDOMETRITIS  177 

If  septicemia  is  present  the  symptoms  are  those  of  chronic 
septicemia;  fluctuating  elevations  in  the  temperature,  rapid  and 
feeble  pulse,  dry  skin,  diarrhea,  the  odor  of  sepsis,  malnutrition,  and 
anorexia. 

There  being  no  septicemia  the  symptoms  are  leucorrhea,  uterine 
hemorrhages,  menstrual  disturbances,  dyspareunia,  sterility,  and 
abortion,  and  symptoms  referable  to  the  digestive  and  nervous 
systems. 

Leucorrhea  is  the  only  constant  symptom.  The  discharge  is 
profuse, — though  varying  in  amount  in  individual  cases.  It  is 
purulent  in  character  and  may  be  mixed  with  blood.  It  is,  as  a 
rule,  odorless  unless  it  has  been  retained  on  the  vulva  and  has 
decomposed  because  of  the  patient's  uncleanly  habits. 

A  history  of  an  acute  attack  of  septic  infection  and  the  character 
of  the  leucorrhea — especially  if  septic  microorganisms  can  be 
found  in  it  upon  microscopic  examination  of  cover-glass  prepara- 
tions— serve  to  distinguish  this  form  of  endometritis  from 

(2)  The  large  number  of  varieties  of  chronic  endometritis  which  are 
not  preceded  by  a  known  acute  stage.  They  may  be  enumerated 
as: — fungous,  villous,  polypoid,  exfoliative,  and  tuberculous. 

The  endometritis  of  the  infectious  diseases — typhoid  fever, 
diphtheria,  scarlet  fever,  measles,  small-pox,  and  syphilis — all 
are  of  a  mild  type. 

Etiology. — Predisposing  causes  of  chronic  endometritis  are: — 
uterine  displacements,  uterine  malformations  (especially  ante- 
flexion),  subin  volution  of  the  uterus,  extensive  lacerations  of  the 
cervix,  tumors  of  the  pelvis,  sexual  excesses,  chronic  constipation, 
the  infectious  diseases,  and  certain  constitutional  diseases, — anemia, 
chlorosis,  rheumatism,  and  lit  hernia. 

The  pathological  processes  present  are  glandular  and  interstitial 
endometritis  as  described  on  pages  170  and  171. 

Symptoms. — The  chief  symptom  is  leucorrhea.  The  patient  does 
not  remember  when  she  first  noticed  a  vaginal  discharge,  so  gradual 
is  its  beginning.  It  is  due  to  the  secretion  of  the  utricular  glands 
plus  that  of  the  vulvo-vaginal  glands.  The  amount  depends  on 
the  condition  of  the  endometrium, — more  when  it  is  hypertrophied 
and  in  the  glandular  variety  of  endometritis,  and  less  in  the  atrophic 
variety.  In  the  fungous  and  polypoid  forms  the  leucorrhea  is  apt 
to  be  bloody,  and,  if  there  is  decomposition  of  tissues,  purulent.  In 


178  THE  DIAGNOSIS  OF  ENDOMETRITIS 

most  of  the  varieties  of  chronic  endometritis  the  discharge  is  thin 
and  serous  in  character. 

AYhen  the  secretion  from  the  cervical  canal  exceeds  in  amount 
that  from  the  body  of  the  uterus  the  discharge  is  thick  and 
viscid  in  consistency.  It  is  without  odor  and  is  unirritating  as 
a  rule1,  although  in  patients  of  uncleanly  habits  it  may  have  a 
foul  odor. 

The  amount  of  discharge  varies  from  a  staining  of  the  linen  to 
several  well-soaked  napkins  a  day;  it  is  increased  for  a  day  or  two 
just  before  and  just  after  each  menstrual  period  because  of  the 
normal  congestion  of  the  genital  organs  at  these  times. 

Hemorrhage  at  the  menstrual  period  or  excessive  menstrual 
flow — styled  menorrhagia — is  to  be  expected  in  the  hypertrophic 
form  of  endometritis;  scanty  flow  in  the  atrophic  forms.  Painful 
menstruation — dysmenorrhea — is  a  pretty  constant  symptom, 
although  it  occurs  in  such  great  variety  of  manifestations  and  at 
such  variable  times  with  reference  to  the  flow  that  it  is  impossible  to 
dogmatize  about  it.  Irregularity  in  the  occurrence  of  menstruation 
also  is  to  be  expected,  variations  of  a  few  days  before  or  after  the 
normal  time  being  common.  • 

Sterility  and  abortion  are  more  often  observed  in  patients  suffer- 
ing from  chronic  endometritis  than  in  women  with  normal  uterine 
organs.  Symptoms  of  general  ill  health  usually  accompany  chronic 
endometritis,  although  it  is  not  always  easy  to  determine  whether 
the  ill  health  is  due  to  the  endometritis  or  the  endometritis  to  the 
ill  health. 

Signs. — The  physical  examination  reveals  a  uterus  enlarged,  but 
not  necessarily  to  a  marked  degree,  and  more  or  less  sensitiveness 
of  the  uterus  to  light  pressure  when  it  is  squeezed  between  the  ex- 
aminer's fingers  during  the  combined  vagino-abdominal  or  recto- 
abdominal  touch.  If  the  uterus  is  occupied  by  polypi  it  will  be  felt 
to  be  fatter  than  normal,  and  often  a  polypus,  having  been  elon- 
gated and  driven  down  by  the  uterine  pressure,  presents  at  the 
external  os. 

On  speculum  examination  a  discharge  is  seen  to  be  issuing  from 
the  external  os.  Its  character  is  noted.  A  tough  stringy  mucus 
is  the  characteristic  of  the  secretion  of  the  glands  of  the  cervix: 
a  thin,  watery  discharge  is  from  the  glands  lining  the  cavity  of  the 
corpus  uteri.  The  alkalinity  of  the  discharge  should  be  tested 


ENDOMETRITIS  AND  GONOCOCCUS  INFECTION  179 

with  a  piece  of  litmus  paper.  In  endometritis  the  reaction  is  often 
neutral  or  even  acid.  The  condition  of  the  neck  of  the  uterus  is 
noted, — whether  lacerated  or  eroded  or  not. 

On  passing  the  uterine  sound  the  cavity  of  the  uterus  is  generally 
found  to  be  enlarged.  In  anteflexion  with  endometritis  the  in- 
ternal os  is  tight,  but  the  operator  will  find  that  by  straightening 
the  canal  by  traction  on  the  cervix  with  a  tenaculum  it  is  always 
possible  to  pass  a  sound  of  small  caliber.  Previous  to  passing  the 
sound  an  accurate  idea  should  be  obtained  as  to  the  probable 
direction  of  the  uterine  canal  by  means  of  the  bimanual  touch. 
Great  gentleness  is  essential. 

If  the  sound  is  passed  with  the  greatest  care  and  blood  flows  after 
its  withdrawal  and  the  cavity  is  tender,  endometritis  may  be 
diagnosed.  Fungosities  and  polypi  are  to  be  detected  in  favorable 
cases  by  the  tactile  sense  transmitted  through  the  sound,  i.e.,  when 
the  canal  is  widely  open  and  reasonably  straight.  Points  of  ten- 
derness in  the  endometrium  and  their  definite  situations  are  deter- 
mined by  the  sound. 

GONORRHEAL   ENDOMETRITIS   AND   GONOCOCCUS   INFECTION 

Gonorrheal  endometritis  merits  special  consideration  because  it 
is  a  very  common  disease  and  has  serious  sequelae. 

As  to  its  frequency  authors  do  not  agree.  It  is  undoubtedly 
more  common  in  the  public  clinics  and  among  prostitutes  than  in 
private  practice.  Zweifel  estimated  that  ten  per  cent  of  his  private 
gynecological  cases  suffered  from  gonorrhea.  Different  writers 
place  gonorrhea  as  the  cause  of  acute  inflammation  of  the  uterus 
and  tubes  in  from  one-half  to  two-thirds  of  the  patients  seen  in  the 
dispensary  services  of  the  large  cities.  This  estimate  includes 
some  of  the  puerperal  cases,  which  form  a  considerable  number  of 
the  total  acute  infections,  for  the  gonococcus,  as  well  as  the  staphy- 
lococcus  and  the  streptococcus,  is  the  cause  of  puerperal  infection. 

The  gonococcus,  a  diplococcus  discovered  by  Neisser  in  1879, 
finds  a  favorite  habitat  in  the  deeper  portions  of  the  mucous  mem- 
branes which  are  covered  with  cylindrical  epithelium.  It  also 
grows  readily  under  pavement  epithelium,  but  can  not  penetrate 
the  squamous  epithelium  as  easily  as  the  columnar. 

Its  favorite  homes  in  the  female  generative  apparatus  when  once 


ISO  THE  DIAGNOSIS  OF  ENDOMETRITIS 

introduced  are,  in  order  of  frequency: — (1)  the  urethra  and 
Skene's  and  Bartholin's  glands;  (2)  the  mucosa  of  the  cervical 
canal ;  (3)  the  upper  portion  of  the  vagina ;  (4)  the  endometrium 
of  the  corpus  uteri;  (5)  the  mucosa  of  the  Fallopian  tubes. 

Although  the  squamous  epithelium  of  the  vagina  of  adults, 
bathed  in  its  acid  secretions  and  protected  by  its  normal  bacterial 
flora,  resists  the  invasion  of  the  gonococcus,  the  tender  vaginal 
mucosa  of  children,  although  covered  by  squamous  epithelium,  is 
easily  penetrated  by  it,  whence  the  frequency  of  vulvo-vaginitis 
among  children. 

The  gonococcus  is  speedily  destroyed  by  other  bacteria  and  their 
toxins  in  the  case  of  a  secondary  infection  in  the  process  of  abscess 
formation,  as  attested  by  the  rarity  with  which  it  is  found  in  the 
contents  of  a  chronic  pyosalpirix ;  on  the  other  hand  it  may  remain 
alive  in  the  mucosa  of  the  cervical  canal  or  in  -Skene's  glands  for  a 
series  of  years.  As  a  rule  gonorrheal  infections  are  uncompli- 
cated by  mixed  infections  with  other  bacteria  unless  trauma 
accompanies  the  infection. 

The  diplococcus  is  always  introduced  from  without — in  little 
children  by  the  contaminated  fingers  of  an  adult  infected  with  the 
diseases  and  by  soiled  linen  or  bath  sponges — in  adults,  as  a  rule, 
by  coitus. 

Gonorrheal  endometritis  invariably  begins  in  the  cervical  canal. 
It  may  be  limited  to  the  cervix  uteri  if  the  internal  os  is  well  closed, 
— as  in  virgins  and  in  anteflexion.  In  multiparous  women  it  is 
prone  to  spread  to  the  corpus  uteri.  Sometimes  the  gonococcus  is 
carried  from  the  cervix  to  the  corpus  uteri  by  the  physician's  sound 
or  uterine  applicator.  The  disease  is  acute  or  chronic. 

Acute  Gonorrheal  Endometritis 

The  disease  is  limited  to  the  cervix,  acute  gonorrheal  endocer- 
vicitls.  The  mucosa  of  the  cervical  canal  is  reddened,  swollen,  and 
bathed  in  pus,  which  sometimes  has  a  greenish  tinge.  The  neck  is 
swollen,  soft,  and  tender  to  the  touch.  Examined  histologically 
the  mucosa  shows  loss  of  epithelium  in  places;  the  uterine  glands 
show  hypertrophy  and  hypoiplasia,  and  the  interglandular  tissue 
is  enormously  infiltrated  with  round  cells  and  polymorphonuclear 
leucocvtes.  The  blood-vessels  are  increased  in  number  and  size. 


ACUTE   GONORRHEAL   ENDOMETRITIS  181 

On  staining  for  the  gonococcus  it  is  found  lying  in  groups  between 
the  epithelial  cells  and  also  in  the  subepithelial  tissue.  The 
gonococci  may  also  be  found  in  the  pus.  They  seldom  penetrate 
the  uterine  muscle  by  way  of  the  lymphatics  as  do  the  streptococci, 
and  when  gonorrheal  inflammation  reaches  the  peritoneum  it  does 
so  by  way  of  the  mucosa  of  the  corpus  uteri  and  of  the  Fallopian 
tubes. 

Symptoms. — The  symptoms  of  acute  gonorrheal  endocervicitis  are 
generally  marked  by  the  symptoms  of  coincident  inflammation  in 
the  urethra,  vulvo- vaginal  glands,  and  vagina.  There  is  a  history 
of  infection.  The  symptoms  are  ushered  in  by  a  chill  followed  by 
an  elevation  of  temperature  and  a  rapid  pulse.  The  patient  com- 
plains of  pelvic  pain,  painful  micturition  and  defecation,  nausea 
and  vomiting,  and,  in  the  course  of  a  few  hours,  there  is  a  leucorrhea, 
— at  first  mucous  in  character,  soon  becoming  purulent  and  some- 
times mixed  with  blood.  The  symptoms  are  not  so  severe  as  in 
acute  septic  endometritis,  and  last  not  over  a  week.  They  are  more 
pronounced  if  the  inflammation  has  extended  to  the  body  of  the 
uterus,  and  still  more  so  if  to  the  Fallopian  tubes.  In  these  cases 
one  looks  for  greater  pelvic  and  abdominal  pains. 

Diagnosis. — The  diagnosis  rests  on  (1)  the  history  of  a  suspicious 
intercourse,  which  was  followed  by  a  purulent  vaginal  discharge, 
and  by  preceding  frequent  and  painful  micturition,  i.e.,  an  acute 
urethritis,  strong  presumptive  evidence  of  gonorrhea:  (2)  the 
symptoms  just  enumerated;  (3)  the  physical  signs.  The  cervix  is 
swollen  and  tender,  and  pus  flows  from  the  os.  If  the  mucosa  of 
the  corpus  uteri  is  also  involved — acute  gonorrheal  endometritis — 
the  entire  uterus  is  enlarged  and  tender  to  bimanual  touch;  (4) 
the  microscopic  examination  of  the  pus  shows  the  presence  of  the 
gonococcus. 

Differential  Diagnosis. — The  acute  form  of  gonorrheal  endome- 
tritis may  be  mistaken  for  acute  septic  endometritis.  In  the 
gonorrheal  form  the  local  and  constitutional  symptoms  are  less 
severe,  there  is  lacking  a  cause  for  sepsis  in  the  form  of  post-puer- 
peral infection  or  mtra-uterine  treatment,  and  on  the  other  hand 
there  may  be  present  a  history  of  a  suspicious  intercourse.  The 
urethra,  Skene's  glands,  and  the  vulvo- vaginal  glands  are  involved; 
then1  may  be  enlargement  of  the  lymphatic  glands  of  the  groin — 
adenitis,  bubo — finally  the  gonococci  are  found  in  the  discharge. 


1S2  THE  DIAGNOSIS  OF  ENDOMETRITIS 

Chronic  Gonorrheal  Endometritis 

Chronic  gonorrheal  endometritis  may  result  from  a  well-marked 
acute  gonorrheal  endometritis.  More  commonly  the  history  of 
an  acute  stage  is  wanting.  The  history  of  frequent  and  painful 
micturition,  either  following  marriage  or  in  a  woman  suspected  of 
having  loose  habits,  whether  married  or  single,  should  lead  the 
physician  to  consider  the  possibility  of  gonorrhea. 

The  onset  of  the  disease  is  generally  insidious;  the  symptoms 
and  physical  signs  are  those  of  the  varieties  of  chronic  endometritis 
due  to  the  saprophytic  and  pyogenic  bacteria. 

The  leucorrhea  in  gonorrheal  endometritis  is  generally  most 
abundant;  it  loses  the  purulent  character  of  the  acute  stage  and 
is  mucous  in  character.  The  diagnosis  depends  on  finding  the 
gonococcus  in  the  discharge  from  the  cervix.  Some  authors  claim 
that  it  is  necessary  to  make  cultures  in  order  to  identify  surely  the 
microorganism,  but  this  view  is  not  held  by  most.  Many  slides 
should  be  examined.  Negative  findings  do  not  rule  out  gonorrhea, 
and  this  brings  us  to  the  consideration  of  latent  gonorrhea. 

Latent  Gonorrhea  in  Women. — Certain  experiments  by  Wertheim 
of  Vienna  (Archiv.  filr  Gyn.,  1892,  XLL,  No.  1),  and  clinical 
observations  by  a  number  of  investigators,  go  to  show  that  the 
gonococcus  loses  its  virulence  after  a  time — weeks  or  months — 
that  when  it  is  planted  in  new  ground,  i.e.,  when  another  indi- 
vidual is  infected,  the  microorganism  recovers  its  former  vitality, 
and  that  when  reintroduced  into  the  original  host  all  the  symp- 
toms and  signs  of  an  acute  attack  of  gonorrhea  are  manifested. 
For  example,  a  man  has  acute  gonorrhea  which  ends  in  a  chronic 
gleet.  He  infects  his  wife  and  later  is  rcinfected  by  her  and  has 
another  acute  attack  of  gonorrhea.  In  the  course  of  time  each 
becomes  tolerant  of  the  gonococci  of  the  other.  The  husband  has 
intercourse1  with  a  prostitute,  suffers  a  fresh  attack  and  reinfects 
his  wife.  This  explains  why  the  gonococcus,  even  after  years  of 
apparent  cure,  may  regain  its  full  virulence1.  Such  authorities  as 
Wassermann  (BcrL  Klin.  Woch.,  1897,  No.  32,  p.  680),  Maslovski, 
DeChristrnas,  and  Jullien  agree  that  there  is  no  immunity  in  gon- 
orrhea, one  attack  giving  no  exemption  from  the  disease  in  the 
future.  It  argues  for  repeated  examinations  of  a  gleety  urethral 
discharge  in  the  male  before  advising  marriage. 


SENILE  ENDOMETRITIS  183 

The  cervical  canal  and  Skene's  glands  in  the  floor  of  the  urethra 
are  the  chief  lurking  places  for  the  gonococcus  in  the  female  genital 
apparatus. 

Differential  Diagnosis  of  Chronic  Gonorrhea!  Endometritis.— 
Chronic  gonorrheal  endometritis  may  be  mistaken  for  the  simple 
forms  of  endometritis.  A  gonorrheal  origin  of  an  endometritis 
may  be  suspected  from  the  history  of  the  case;  — an  acute  attack 
with  purulent  discharge  and  painful  micturition  following  a  sus- 
picious intercourse.  Occasionally  there  is  a  history  of  the  patient 
having  had  a  bubo  or  gonorrheal  inflammation  of  the  joints.  More 
commonly  no  such  history  is  obtainable.  It  is  seldom  advisable 
to  institute  too  minute  inquiries  in  this  direction  in  the  case  of 
married  women  because  of  the  risk  of  causing  trouble  between 
husband  and  wife, — trouble  which  can  not  be  cured  by  the  physician. 

Tubal  disease  is  found  in  conjunction  with  all  forms  of  endome- 
tritis, but  more  commonly  with  the  septic  and  gonorrheal  forms. 

In  most  cases  repeated  bacteriological  examinations  of  the  dis- 
charge from  the  cervix  are  the  only  way  of  distinguishing  to  a 
certainty  the  cause  of  the  inflammatory  process.  The  results  of  the 
examinations  are  so  often  negative  that  we  are  left  with  only  a 
probable  diagnosis  founded  on  the  history  alone. 

SENILE  ENDOMETRITIS 

Senile  endometritis  is  an  atrophic  form  of  endometritis  occurring 
in  women  who  have  passed  the  menopause,  occurring  particularly 
in  poorly  nourished  subjects.  It  is  due  to  the  infection  of  the 
atrophying  mucosa,  but  what  causes  the  infection  is  not  known. 
Pathologically  the  endometrium  is  found  thinned,  the  glandular 
elements  are  wanting,  and  many  times  the  endometrium  is  entirely 
replaced  by  connective  tissue.  There  may  be  stenosis  of  the 
uterine  cavity  from  adhesion  of  the  walls,  and,  from  the  same  cause, 
the  retained  secretions  may  form  a  senile  pyometra  or  hydromctra. 
The  latter  is  very  rare.  The  symptoms  have  an  insidious  onset,  a 
thin,  purulent,  often  offensive  and  irritating  vaginal  discharge 
being  the  chief  symptom.  Pruritus  vulvie  is  common,  also  vulvitis. 
Sometimes  the  discharge  is  tinged  with  blood.  There  may  be 
symptoms  of  mild  sepsis  if  the  discharges  are  retained,  and  in  this 
case  pelvic  pains  are  to  be  expected. 


1S4  THE   DIAGNOSIS  OF  EXDOMETRITIS 

The  physical  signs  show  the  uterus  to  he  small  (unless  there  is 
pyometra),  and  the  cervix  uteri  is  atrophied.  An  attempt  to  pass 
the  sound  will  reveal  partial  or  complete  atresia  of  the  uterine  canal. 
If  the  canal  is  patent  the  discharge  is  seen  issuing  from  the  os.  The 
disease,  coming  as  it  does  after  the  menopause  and  attended  as  it  is 
by  a  foul  discharge,  may  be  mistaken  for  carcinoma  of  the  cervical 
canal  or  body  of  the  uterus.  Dilatation  and  curetting,  with  an 
examination  of  the  tissue  removed,  will  settle  a  doubt. 

EXDOCERVICITIS 

Endocervicitis  is  a  chronic  inflammation  of  the  mucosa  of  the 
cervical  canal.  It  is  called  also  cervical  catarrh  and  cervical 
endometritis.  The  disease  is  confined  to  the  cervix  uteri, — there 
is  no  extension  to  the  mucosa  of  the  corpus  uteri.  This  is  a  common 
affection.  The  gonorrhea!  form  has  been  described  under  chronic 
gonorrheal  endometritis.  Lacerations  of  the  cervix  are  a  frequent 
cause.  When  the  cervix  is  torn  the  lips  become  everted  and  are 
subjected  to  trauma  from  (1)  pressure  on  the  posterior  wall  of  the 
vagina  by  scybalous  masses  in  the  rectum  resting  on  the  unyielding 
sacrum,  or  (2)  from  excessive  coitus.  Another  common  cause  of 
endocervicitis  are  polypi  originating  either  in  the  mucosa  of  the 
cervix  or  corpus. 

The  cervical  tissues  in  endometritis  become  hypertrophied,  the 
mucosa  is  eroded,  and  cystic  degeneration  develops.  Infection  is 
difficult  to  dislodge  as  the  bacteria  occupy  the  glandular  crypts. 

EROSION'S    OF    THE    CERVIX    UTERI 

Characteristics. — Erosions  of  the  cervix  uteri  are  characterized 
by  a  dark  red  or  purplish  color  of  the  tissues  immediately  around 
the  external  os  uteri.  Having  the  appearance  of  ulceration  they 
were  formerly  believed  to  be  true  ulcers. 

In  an  erosion  there  is  no  inflammatory  action  accompanied  by 
destruction  of  the  epithelium  as  in  ulceration.  The  surface 
squamous  epithelium,  which  normally  covers  the  cervix,  is  re- 
moved,— it  is  eroded, — and  the  underlying  columnar  epithelium  is 
hypertrophied. 

(1)  .-1  simple  erosion  presents  a  uniformly  smooth,  velvety  surface 


EROSIONS  OF  THE  CERVIX  UTERI 


185 


with  sharply  defined  edges.  On  microscopic  examination  it  is 
seen  to  consist  of  a  single  layer  of  columnar  epithelium  with  little 
or  no  formation  of  new  glands. 

(2)  A  papillary  erosion  has  an  irregular  projection  of  its  livid 
red  surface  and  has  been  called  "cock's-comb  granulations."     Here 
the  microscope  shows  deep  invaginations  of  the  columnar  epithe- 
lium to  form  glands,  alternating  with  elevations  made  up  of  newly 
formed  connective  tissue  and  round  cells.     The  glands  secrete  a 
viscid  mucus. 

(3)  A  follicular  erosion  is  one  in  which  retention  cysts — the  so- 


FIG.  69. — Erosion  of  the  Cervix  with  Lacerations. 
(H.  Macnaughton-Jones.) 

called  Nabothian  follicles — are  present  in  considerable  number. 
These  cysts  are  formed  by  the  occlusion  of  the  newly  formed  glands 
referred  to  in  the  description  of  the  papillary  erosion.  They  are 
filled  with  inspissated  mucus  and  vary  in  number.  There  may  be 
half  a  dozen,  or  the  cervix  may  be  fairly  riddled  with  them.  In 
size  they  vary  from  a  B.H.  shot  to  an  English  walnut  in  extreme 
cases.  They  are  usually  not  larger  than  a  pea.  To  the  examining 
finger  the  retention  cyst  feels  like  a  shot;  to  the  eye  it  appears  as 
a  little  rounded  elevation  of  a  bluish-white  or  yellow  color. 

Diagnosis. — Leucorrhea  is  the  constant  symptom  of  endocervi- 
citis.  The  diagnosis  is  made  by  digital  and  speculum  examinations. 
The  finger  detects  lacerations,  the  soft  velvety  surface  of  the 


ISO  THE  DIAGNOSIS  OF  EXDOMETRITIS 

erosion,  the  stringy  plug  of  mucus  in  the  os,  shot-like  retention 
cysts,  and  tenderness  of  the  tissues  of  the  cervix.  The  speculum 
shows,  the  scars  of  the  lacerations  and  thus  their  extent,  the  dull 
red  roughened  surface  of  the  erosion,  the  plug  of  mucus  in  the  os, 
polypi,  and  retention  cysts,  if  they  exist.  The  fact  that  erosions 
are  found  in  the  virgin  and  even  in  the  infant  (see  Chapter  XXVIII., 
page  563)  must  be  borne  in  mind.  The  determining  factor  in 
the  causation  of  this  condition  seems  to  be  the  exposure  of  the 
columnar  epithelium  with  which  the  canal  of  the  cervix  is  lined 
to  the  conditions  which  obtain  in  the  vagina  where  the  mucous 
membrane  is  paved  with  squamous  epithelium. 

Differential  Diagnosis. — The  differential  diagnosis  concerns  itself 
with  the  exclusion  of  ulceration  due  to  (1)  an  ill-fitting  pessary, 
(2)  to  tuberculosis;  (3)  to  chancre  or  chancroid,  and  (4)  to 
carcinoma.  All  forms  of  true  ulceration  are  rare, — erosions  are 
common. 

(1)  Ulceration  from  an  lU-fitting  Pessary. — If  an  ill-fitting  pessary 
has  been  removed  and  the  ulceration  does  not  promptly  heal  under 
appropriate  treatment  a  piece  of  tissue  should  be  excised  under 
cocaine  anesthesia  and  examined  microscopically. 

(2)  Tuberculous  Ulcer. — Evidences  of  tuberculosis  elsewhere  in 
the  body,  a  history  of  tuberculosis,  and  microscopic  examination 
of  the  discharge  and  a  piece  of  excised  tissue,  will  establish  the 
diagnosis. 

(3)  (a)  Chancre. — The   history   is  an   important   consideration. 
A  definite  period  of  incubation  of  the  disease  is  present  and  the 
symptomatology    and    signs    are   those    of   syphilis.     Chancre    is 
seldom  seen   in  the  initial   stage,    i.e.,   before  ulceration.     When 
ulcerated  it  is  a  single  ulcer.     The  ulcer  heals  under  antisyphilitic 
treatment.     The    differentiation   of  the  Spirochieta  pallida  in  a 
piece  of  tissue  removed  for  microscopic  examination  makes  the 
diagnosis  certain. 

(b)  Chancroid. — Here  one  finds  multiple  ulcers  appearing  soon 
after  a  suspicious  intercourse  and  no  symptoms  of  syphilis. 

(4)  Carcinomatous   Ulceration*. — These    are   generally   attended 
by  much    thickening  of    the    surrounding    tissues   and  bleeding. 
A   piece  of  tissue  should  be  excised  and  sent  to  the  pathologist  for 
microscopic  examination. 


CHAPTER  XII 

THE   DIAGNOSIS   OF  "PELVIC   INFLAMMATION 

(Pelvic  Peritonitis  and  Pelvic  Cellulitis) 

Definitions,  pelvic  peritonitis  and  pelvic  cellulitis,  p.  187.  Routes  of 
infection  in  pelvic  inflammation,  p.  187. 

Pelvic  peritonitis,  p.  188:  Anatomy,  p.  188.  Etiology,  p.  189.  Varieties, 
p.  190;  Acute  pelvic  peritonitis,  p.  190.  Chronic  pelvic  peritonitis,  p.  191; 
Tuberculous  peritonitis,  p.  191. 

Pelvic  cellulitis,  p.  192:  Anatomy,  p.  192.  Etiology  and  pathology,  p.  192; 
Pelvic  abscess,  p.  193.  Symptoms,  p.  193.  Diagnosis,  p.  194. 

Table  of  differential  diagnosis  of  pelvic  inflammation,  p.  195. 

Definition. — The  term  pelvic  inflammation  signifies  broadly 
inflammatory  action  situated  in  any  of  the  structures  occupying 
the  pelvis.  It  will  be  used  in  this  chapter  to  mean  inflammation 
in  the  peritoneum  which  covers  the  pelvic  organs,  and  in  the  under- 
lying cellular  connective  tissue  of  the  pelvis. 

The  inflammatory  process  when  confined  to  the  pelvic  peritoneum 
constitutes  a  pelvic  peritonitis,  and  when  in  the  pelvic  cellular 
tissue  a  pelvic  cellulitis. 

Pelvic  Peritonitis. — This  is  a  very  common  affection  and  accom- 
panies inflammatory  affections  of  .the  ovaries  and  tubes,  as  well  as 
inflammation  of  the  peritoneum  of  the  entire  peritoneal  cavity. 
The  inflammation  extends  to  the  cellular  tissue  from  propinquity 
and  therefore  the  two  processes  are  often  combined. 

Pelvic  Cellulitis. — This,  on  the  other  hand,  is  a  rare  affection 
following  labor  or  abortion  and  exhibits  less  tendency  to  extend  to 
the  peritoneum  and  to  the  overlying  structures.  It  is  often  im- 
possible to  differentiate  between  the  two  varieties  of  pelvic  inflam- 
mation, especially  in  the  later  stages.  An  attempt  will  be  made 
to  describe  both  forms,  beginning  with  the  more  important:  first, 
saying  something  of  the  routes  of  infection  and  the  character  of 
the  structures  involved. 

Routes  of  Infection  in  Pelvic  Inflammation. — Infection  may  reach 
the  pelvic  peritoneum  and  cellular  tissue  (1)  from  the  outside, 
through  the  lumen  of  the  vagina,  uterus,  and  tubes,  or  (2)  from  the 
blood  current  and  the  lymphatics. 

is7 


188  THE  DIAGNOSIS  OF  PELVIC   INFLAMMATION 

1.  It  is  possible  for  infection  to  travel  through  the  vagina,  uterus, 
and  tubes  without  leaving  traces  behind  it.     Often,  at  the  time  the 
patient  first  conies  under  observation,  the  inflammatory  processes 
in  these  structures  have  burned  themselves  out. 

2.  The  blood  or  lymph  vessels  may  bring  infection  to  the  pelvis 
from  distant  organs,  though  this  is  rare.     Generally  the  infective 
microorganism  is  near  at  hand  either  in  the  uterus,  tubes,  bladder, 
01-  rectum,  rarely  in  an  infected  ovarian  cyst,  a  suppurating  appen- 
dix vermiforrnis,  or  the  large  or  the  small  intestine. 

Occasionally  infection  comes  to  the  pelvis  in  a  psoas  abscess  or 
other  abscess  of  distant  origin,  such  as  an  abscess  about  the  sacro- 
iliac  or  hip  joints.  The  following  bacteria  have  been  found  in 
cases  of  pelvic  inflammation,  generally  in  mixed  culture,  and  they 
may  be  classed  as  causative  of  the  inflammation: — 

Gonococcus. 

Colon  bacillus. 

Streptococcus  pyogenes. 

Staphylococcus  pyogenes  albus,  aureus,  and  citrous. 

Tubercle  bacillus. 

Diphtheria  bacillus. 

Typhoid  bacillus. 

Pneumococcus. 

Actinomyces. 

PELVIC    PERITONITIS 

ANATOMY 

The  pelvic  peritoneum  covers  the  concave  surface  of  the  floor 
of  the  pelvis.  Beginning  on  the  anterior  wall  of  the  abdomen 
behind  the  pubes  and  passing  downward  and  backward,  it  covers 
first  the  posterior  surface  of  the  bladder.  In  this  situation  it  is 
loosely  adherent  and  has  more  or  less  cellular  tissue  under  it. 
From  the  bladder  it  reaches  the  uterus  just  below  the  level  of  the 
internal  os  and  thence  rises  over  the  anterior  aspect  of  the  body  of 
the  uterus.  This  lowest  portion  forms  the  so-called  vesico-uterine 
pouch.  Passing  over  the  fundus  of  the  uterus,  where  it  is  closely 
adherent,  the  peritoneum  is  continued  on  the  posterior  surface 
of  the  bod)'  of  the  uterus  to  a  point  a  little  below  the  level  of  the 
internal  os  where  it  leaves  the  uterus  to  dip  down  deep  in  the  pelvis 


PELVIC  PERITONITIS  189 

to  form  the  cul-de-sac  of  Douglas.  Its  lowest  point  in  the  cul-de-sac 
varies,  but  averages  half  an  inch  or  so  below  the  attachment  of  the 
vagina  to  the  cervix.  Rising  from  the  cul-de-sac  of  Douglas,  the 
peritoneum  reaches  first  the  anterior  part  of  the  middle  portion  of 
the  rectum.  Higher  up  it  reaches  the  sides  of  this  viscus  and  still 
higher  the  posterior  portion  of  the  first  part  of  the  rectum.  At 


FIG.  70. — Reflections  of  the  Folds  of  the  Peritoneum 
(Dotted  Lines). 

the  sides  of  the  uterus  the  folds  of  the  peritoneum  form  the  broad 
ligaments.  Above  they  cover  the  Fallopian  tubes  and  the  posterior 
surfaces  of  the  ovaries. 

ETIOLOGY 

Pelvic  peritonitis,  the  more  common  of  the  two  soils  of  pelvic 
inflammation,  is  almost  always  secondary  to  salpingitis.  It  may 
follow  the  escape  of  pus  or  even  menstrual  blood  or  injected  fluid 
from  the  ostium  abdominale  of  the  Fallopian  tube,  or  it  may  follow 
septic  metritis,  cystitis,  proctitis,  perforation  of  the  uterus,  appendi- 
citis, or  psoas  abscess. 

The  gonococeus  and  streptococcus  are,  as  far  as  we  know,  the 
bacteria  most  frequently  the  cause  of  pelvic  peritonitis. 


190  THE  DIAGNOSIS  OK  PELVIC  INFLAMMATION 

VARIETIES 

Tin;  disease  is  acute  or  chronic. 

Acute  Pelvic  Peritonitis. — This  is  manifested  by  sharp  pains  in 
the  lower  abdomen  and  pelvis,  rigidity  of  the  abdominal  muscles, 
tenderness  to  examination  both  of  the  abdomen  and  the  vagina, 
fever,  rapid  pulse,  nausea,  vomiting,  constipation,  and  nervous 
depression. 

The  greater  the  tendency  of  the  peritonitis  to  become  a  general 
peritonitis,  the  more1  pronounced  are  the  symptoms.  If  the  resist- 
ing power  of  the  individual  is  great,  i.e.,  a  high  opsonin  index  is 
present,  and  the  virulence  of  the  infecting  bacteria  little,  or  the 
dose  small,  the  inflammation  may  subside,  leaving  behind  it  ad- 
hesions between  the  opposing  folds  of  peritoneum.  Thus  the  tubes 
become  glued  in  the  cul-de-sac  frequently,  and  coils  of  intestine 
are  fastened  to  the  tubes.  In  the  severer  grades  of  inflammation 
the  omcntum  helps  to  wall  off  the  process  from  the  general  cavity 
of  the  peritoneum.  It  applies  itself  to  an  inflamed  tube  in  an 
almost  intelligent  manner.  If  resolution  does  not  occur  because 
of  the  great  virulence  of  the  infective  material  or  lessened  resistance 
of  the  patient,  a  chronic  pelvic  peritonitis,  or  a  pelvic  abscess, 
results.  Without  treatment  such  a  pelvic  abscess  most  commonly 
opens  into  the  rectum,  although  it  may  find  exit  into  the  bladder  or 
through  the  abdominal  wall.  It  very  rarely  opens  into  the  uterus 
or  vagina. 

The  diagnosis  is  established  by  the  presence  of  the  symptoms 
above  noted  and  by  the  physical  signs,  which  are: — on  bimanual 
examination  the  vagina  is  hot,  denoting  increased  body  tempera- 
ture; the  uterus  is  fixed  and  there  is  a  sense  of  resistance  in  the 
tissues  occupying  the  pelvis,  a  board-like  feeling.  This  induration 
of  the  pelvic  tissues,  coupled  with  the  rigidity  of  the  abdominal 
walls  and  great  tenderness  to  light  pressure,  make  it  impossible  to 
map  out  the  contents  of  the  pelvis  with  exactness.  A  tumor  mass, 
if  present,  is  high  up  in  the  pelvis.  The  uterus  may  or  may  not  be 
misplaced  according  to  the  situation  of  the  greatest  amount  of 
exudate.  If  there  is  an  abscess  present  a  point  of  softening  is  to 
be  searched  for.  Abscess,  however,  is  generally  rare  and,  if  present, 
occurs  in  the  later  stages  of  pelvic  peritonitis.  Speculum  examina- 
tion aids  little  in  the  diagnosis  of  this  affection.  The  uterine 


CHRONIC  PELVIC  PERITONITIS  191 

discharges  are  diminished  at  the  onset  and  increased  in  the  later 
stages.  The  detection  of  a  vaginitis  may  show  the  origin  of  a  pelvic 
peritonitis  and  the  isolation  of  an  infective  bacterium  may  show  its 
nature.  So  also,  examination  of  the  rectum  or  bladder,  should 
symptoms  point  the  way,  may  help  us  to  find  the  route  taken  by 
the  infecting  agent  in  reaching  the  pelvic  peritoneum.  Examina- 
tion of  the  blood  generally  shows  an  increase  in  the  number  of  white 
cells,  although  this  is  not  an  invariable  concomitant. 

Chronic  Pelvic  Peritonitis. — This  begins  with  an  acute  attack, 
although  the  symptoms  may  be  of  inconsiderable  moment,  so  as  to 
escape  the  patient's  notice.  Often  there  will  be  a  history  of  a 
series  of  acute  attacks  separated  by  intervals  of  months  or  years. 
The  symptoms  are  pain  of  a  dull  character  in  the  pelvic  region, 
backache,  constipation  and  painful  defecation,  disturbance  of 
bladder  function,  and  poor  health.  Physical  examination  reveals 
a  larger  or  smaller  amount  of  exudate  and  limitations  of  the 
mobility  of  the  uterus,  tubes,  and  ovaries  due  to  adhesions.  These 
organs  are  apt  to  be  displaced  as  well  as  enlarged.  Tenderness  in 
the  chronic  stage  is  not  a  prominent  factor  as  in  the  acute  form. 

Pelvic  abscess  may  result  in  the  course  of  a  chronic  pelvic  peri- 
tonitis. This  will  be  described  more  in  detail  under  pelvic  cellulitis, 
as  it  is  more  often  found  in  the  latter  affection. 

Tuberculous  Peritonitis. — Tuberculous  peritonitis  is  one  variety 
of  chronic  pelvic  peritonitis.  Here  the  disease,  as  seen  clinically, 
is  seldom  limited  to  the  pelvis,  being  an  affair  of  the  general  peri- 
toneum. 

The  disease  begins  in  the  Fallopian  tubes  in  a  vast  majority  of 
instances,  and  is  sometimes  seen  and  diagnosed  before  it  has 
reached  the  general  peritoneal  cavity.  It  is  characterized  by  a 
gradual  onset,  by  fever  recurring  every  evening  and  disappearing 
in  the  morning,  rapid  pulse,  sweating,  particularly  at  night,  loss 
of  weight,  loss  of  strength,  and  anorexia.  As  the  disease  progresses 
there  is  enlargement  of  the  abdomen  due  to  the  presence  of  plastic 
exudate  or  to  the  accumulation  of  fluid.  Early  in  the  disease 
nothing  characteristic  can  be  made  out.  An  enlargement  of  a  tube, 
with  surrounding  exudate,  increasing  in  size  when  examined  at 
repeated  intervals,  coupled  with  a  family  history  of  tuberculosis, 
previous  tuberculosis  in  some  other  organ,  and  the  symptoms  just 
enumerated,  make  a  probable  diagnosis  of  tuberculous  pelvic  per- 


192  THE  DIAGNOSIS  OF  PELVIC   INFLAMMATION 

itonitis.  Elimination  of  the  other  causes  of  salpingitis,  such  as 
gonorrhea,  may  be  of  assistance'.  The  disease  is  found  most  often 
in  virgins.  In  chronic  pelvic  peritonitis  we  do  not  expect  to  find 
leucocytosis,  even  if  an  abscess  is  present,  although  it  may  occur. 
Pelvic  peritonitis  leaves  behind  it  many  disabling  lesions  in  the 
shape  of  adhesions  and  displacements.  It  is  the  cause  of  a  large 
portion  of  the  diseases  peculiar  to  women,  and  therefore  should 
receive  most  careful  attention  at  the  hands  of  the  physician. 

PELVIC  CELLULITIS 

ANATOMY 

The  cellular  tissue  of  the  pelvis  lies  under  the  peritoneum.  In 
it  pass  the  blood-vessels,  arteries  and  many  large  veins,  and 
the  lymphatics.  It  is  most  abundant  in  the  bases  of  the  broad 
ligaments  and  between  the  peritoneum  of  Douglas'  pouch  and  the 
vagina  and  lower  rectum.  Therefore,  these  are  the  situations 
where  the  cellulitis  occurs  most  often.  The  peritoneum  is  pretty 
closely  attached  to  the  uterus,  Fallopian  tubes,  and  ovaries.  That 
is  to  say,  very  little  cellular  connective  tissue  is  present  under  the 
peritoneum  in  these  regions.  It  is  less  closely  attached  to  the 
bladder. 

ETIOLOGY  AND  PATHOLOGY 

Pelvic  cellulitis  is  a  relatively  rare  affection.  In  more  than 
two-thirds  of  the  cases  it  is  of  puerperal  origin,  and  is  generally 
due  to  infection  by  the  common  pus-producing  cocci  which  enter 
the  pelvic  cellular  tissue  from  the  uterus.  Infection  may  come 
from  the  vagina,  rectum,  or  bladder,  or  from  unclean  instrumenta- 
tion or  septic  manipulation.  The  trauma  incident  to  parturition 
opens  the  way  for  the  entrance  of  bacteria.  The  common  situa- 
tions of  the  inflammation  have  been  foreshadowed  in  the  descrip- 
tion of  the  situations  in  the  pelvis  where  cellular  tissue  is  most 
abundant.  The  lymph  vessels  and  veins  are  affected  first.  A 
lymphangitis  or  a  phlebitis  may  be  limited  by  the  plugging  of  a 
vessel  by  a  thrombus,  and  in  such  a  case  infection  goes  no  farther. 

In  pelvic  cellulitis  the  infective1  process  extends  to  the  tissue 
about  the  vessels,  the  cellular  tissue,  and  we  have  a  cellulitis. 


PELVIC  CELLULITIS  193 

The  infective  inflammation  may  go  through  all  three  of  the  initial 
stages  of  inflammation,  i.e.,  congestion,  effusion,  and  suppuration, 
or  only  the  first,  or  the  first  two.  The  process,  from  a  pathological 
point  of  view,  is  not  so  different  from  that  of  a  furuncle,  namely, 
infection  conveyed  into  a  connective-tissue  area. 

Pelvic  Abscess. — If  the  process  goes  on  to  suppuration  the  pus 
is  evacuated  in  time  spontaneously  into  the  vagina  or  other  pelvic 
viscera,  often  doing  a  good  deal  of  damage  before  this  issue  is 
attained.  Should  the  abscess  open  into  the  bladder  or  rectum, 
it  is  unlikely  to  heal  and  the  patient  becomes  septic  and  dies  from 
septicemia  after  a  long  illness.  This  is  frequently  the  result  even 
if  most  thorough  drainage  is  made,  provided  intervention  has 
been  postponed  until  the  abscess  has  burrowed  extensively  into 
the  tissues  of  the  pelvis  and  the  resisting  powers  of  the  patient 
have  been  reduced  to  low  limits.  Early  surgical  intervention 
and  drainage  of  the  abscess  into  the  vagina  result  in  speedy  heal- 
ing, just  as  in  the  case  of  a  boil,  with  nothing  left  behind  except 
malposition  of  the  uterus,  tubes,  and  ovaries,  and  rarely  dislocation 
of  the  bladder,  or  stricture  of  the  rectum  or  urethra. 

There  is  no  tendency  to  recurrence  and  no  chronic  process  as 
in  the  case  of  pelvic  peritonitis,  where  the  inflammation  originates 
in  the  Fallopian  tube,  which  is  lined  with  mucous  membrane. 
It  is  a  well-known  fact  that  infection  tends  to  lurk  in  mucous 
membranes,  and  it  does  not  remain  in  the  cellular  tissue.  Forms 
of  chronic  cellulitis  have  been  described,  such  as  the  chronic  atrophic 
cellulitis  of  Freund,  also  an  edematous  form.  It  is  a  question,  how- 
ever, whether  such  processes  really  originate  in  the  cellular  tissue. 

A  pelvic  abscess  may  result  from  a  rupture  of  a  pyosalpinx  into 
the  cellular  tissue  of  the  broad  ligament  or  of  the  retro-uterine 
space.  In  this  case  one  would  expect  that  the  healing  process 
would  be  more  protracted,  and  such  is  generally  the  case.  So  also 
in  severe  grades  of  cellulitis  originating  in  the  uterus,  the  over- 
lying tubes  and  ovaries  become  infected  by  extension  and  have 
to  be  reckoned  with  in  the  treatment  and  prognosis. 

SYMPTOMS 

The  symptoms  of  pelvic  cellulitis  are  (a)  general,  those  common  to 
infections,  i.e..  fever,  rapid  pulse,  chills,  prostration;  and  (6)  local, 

13 


194  THE  DIAGNOSIS  OF  PELVIC  INFLAMMATION 

severe  pain  in  the  pelvis,  sensitiveness  to  light  touch,  both  of  the 
abdomen  and  the  vagina,  also  dysuria  and  painful  defecation.  The 
local  symptoms  abate  quickly,  even  if  the  process  goes  on  to  sup- 
puration, and  most  rapidly  if  resolution  occurs. 


DIAGNOSIS 

By  conjoined  manipulation  there  is  found  a  tumor  in  the  pelvis 
occupying  the  region  of  the  broad  ligament  on  one  side,  or  the 
retro-uterine  space  behind.  The  recto-abdominal  touch  is  espe- 
cially useful  in  diagnosing  this  affection.  If  the  mass  is  in  the 
usual  situation  in  the  base  of  the  broad  ligament,  the  uterus  is 
crowded  to  the  opposite  side,  the  tumor,  which  is  hard  or  boggy 
to  the  feel,  bulges  into  the  vagina.  If  the  tumor  is  in  the  retro- 
uterine  space  the  lumen  of  the  vagina  is  encroached  upon  and  the 
bladder  and  cervix  are  crowded  forward  against  the  pubes  and 
anterior  abdominal  wall.  In  the  acute  stage  there  is  rigidity  of  the 
abdominal  muscles,  as  well  as  sensitiveness,  so-called  peritonismus. 
This  soon  subsides.  In  the  later  stages  when  there  is  abscess  for- 
mation it  is  difficult  to  find  the  situation  of  the  uterus  without 
the  aid  of  a  sound.  There  is  a  mass  in  the  pelvis  that  may  occupy 
nearly  the  entire  cavity.  The  pus  generally  burrows  into  the 
retro-uterine  space.  Rectal  examination  will  often  show  the 
upper  limits  of  the  tumor;  combined  rectal  and  vaginal  examina- 
tion is  always  of  value  in  mapping  out  the  size  and  form  of  the 
sort  of  cellulitis  that  begins  in  the  retro-uterine  cellular  space. 
In  some  case's  there  is  marked  edematous  thickening  in  the  space 
between  the  upper  and  middle  portions  of  the  vagina  and  the 
rectum.  This  is  palpated  with  great  exactness  by  one  finger  in 
the  rectum  and  another  in  the  vagina.  The  detection  of  fluctua- 
tion in  a  pelvic  abscess  in  not  easy  because  thick  walls  of  lymph 
are  effused  and  encompass  a  collection  of  pus  of  any  considerable 
size. 

Often  an  effusion  of  blood  in  the  peritoneal  cavity,  a  pelvic 
hematocele  of  several  weeks'  standing,  simulates  a  pelvic  abscess. 
The  hematocele  should  have  a  boggy  feeling,  not  unlike  feces  of 
pasty  consistency,  but  on  account  of  the  wall  of  organized  lymph 
with  which  it  is  surrounded  and  the  tension  of  the  contents  of  the 
sac  there  may  be  no  boggy  feeling.  The  history  of  the  beginning 


DIFFERENTIAL  DIAGNOSIS  OF  PELVIC  INFLAMMATION      195 

of  the  attack,  if  obtainable,  will  throw  light  on  the  diagnosis, 
hematocele  being  ushered  in  by  severe  pain  and  rectal  tenesmus, 
and  with  prostration  but  no  fever.  Pelvic  cellulitis  always  begins 
with  fever. 

The  sequela?  of  pelvic  cellulitis  are  not  so  serious  as  those  of 
pelvic  peritonitis.  Neglected  cases  may  leave  crippling  traces 
because  of  the  involvement  of  ovaries,  tubes,  rectum,  ureter,  or 
bladder.  Cases  which  end  in  speedy  resolution,  either  spon- 
taneously or  because  of  prompt  surgical  interference,  often  leave 
no  other  traces  than  a  cicatrix,  or  a  small  area  of  induration  in 
the  vagina. 


DIFFERENTIAL  DIAGNOSIS  OF  PELVIC  INFLAMMATION 

The  following  table  of  the  differential  diagnosis  of  pelvic  inflam- 
mation has  been  modified  from  that  in  E.  C.  Dudley's  "  Text- 
book of  Gynecology": 


Pelvic  Peritonitis. 

A.  Exudate  surrounds  uterus  and  is 
apt  to  be  high  in  pelvis. 

B.  Uterus  fixed  wherever  it  happens 
to  be. 

C.  Pain   severe   and   paroxysmal   in 
acute  stage. 

D.  Tendency    to    suppuration    not 
marked. 

E.  Frequently     results     in     general 
peritonitis. 

I-1.  Constitutional  symptoms  more 
severe.  Apt  to  be  nausea  and  vomit- 
ing. 

Pelvic  Peritonitis  in  Douglas'  Cul-de-sac. 

A.  Tumor  mass  lias  a  sharp  outline 
and  is  relatively  high  in  pelvis. 


B.  Uterus  is  displaced  forward. 


Pelvic  Cellulitis. 

A.  Tumor   usually   at   one   side   of 
uterus  and  low  in  pelvis. 

B.  Uterus    displaced    laterally,    not 
necessarily  fixed. 

C.  Pain  less  severe  and  more  con- 
tinuous. 

D.  Tendency  to  suppuration  marked. 

E.  Seldom    results   in    general   per- 
itonitis. 

F.  Constitutional      symptoms      less 
severe.     No  nausea  and  vomiting. 


Retro-uterine  Cellulitis. 

A.  Tumor  mass  of  indefinite  outline 
is  situated  in  the  space  between  rectum, 
vagina,  and  uterus  in  pelvic  floor  and 
is  flattened  in  form. 

B.  Cervix  uteri  alone  bent  forward 
or  to  the  side,  not  the  body  and  fundus. 


UK; 


THE   DIAGNOSIS  OF  PELVIC   INFLAMMATION 


Pyosalftinx. 


Pdric  Cellulitis. 


A.   Ma.ss    on    one    or    both    sides    of  A.   Mass  on  one  side  of  uterus  only 

uterus  and  hack  of  it.  not  bulging  into  and  low  in  the  pelvis,  bulging  into  the 

the  vagina.  vagina. 

H.  Mass  of  sharp  outline  and  sausage-  15.  A  diffuse  swelling, 
shaped. 

C.   Mass  partly  movable.  C.  Mass  fixed. 


Chronic  Pelvic  Hematocelc. 

A.  History  of  tubal  pregnancy  with 
symptoms  of  sudden  internal  hemor- 
rhage. May  be  repeated  light  attacks. 

H.   No  chill  or  fever. 

C.  Relatively  rapid  increase  in  size 
of  tumor. 

1).  Tumor  doughy  and  elastic. 

Appendicitis  tcit/t  Abscess. 

A.  Onset  with  severe  symptoms  and 
nausea  and  vomiting. 

H.  Tenderness  over  appendix  region. 

C.  Kxudate  high  up  in  pelvis. 
Reached  by  vaginal  or  rectal  examina- 
tion only  with  difficulty. 


Psnas  A  bscess. 

A.  History  and  symptoms  of  tuber- 
culosis. 

B.  Evidences  of  Pott's  disease. 

C.  No  history  of  acute  onset. 

1).   Limitation  of  motion  and  pain  in 
thigh. 

Subserous  Myoma. 

A.  No  history  of  infection. 

B.  No  history  of  acute  onset. 

C.  Contour   of   the    tumor   rounded, 
sharply  defined,  and  tumor  intimately 
connected  witli  the  uterus. 


Pdric  Cellulitis. 
A.  History  of  infection. 

15.  Chills  and  fever. 

C.  Slow  development  of  tumor. 

D.  Tumor  hard  until  suppuration. 

Pdric  Cellulitis  (Right  Side). 

A.  Onset  with  less  severe  symptoms; 
no  nausea  and  vomiting. 

B.  No     tenderness    over     appendix 


C.  Exudate  low  in  pelvis  in  base  of 
broad  ligament  or  in  retro-uterine  space. 
Easily  palpated  through  vagina  and 
rectum. 

Pdric  Cellulitis. 

A.  History    of    non-tuberculous    in- 
fection. 

B.  No  evidences  of  Pott's  disease. 

C.  History  of  acute  onset. 

D.  No  limitation  of  motion  or  pain 
in  thigh. 

Pelric  Cellulitis. 

A.  History  of  infection. 

B.  History  of  acute  onset. 

C.  Tumor  of  indefinite  outline  and 
not   so  intimately  connected  with  the 
uterus. 


CHAPTER  XIII 

THE   DIAGNOSIS   OF   CONGENITAL   ANOMALIES   OF  THE 

UTERUS,  LACERATION  OF  THE  CERVIX  UTERI,  AND 

DISEASES  OF  THE  UTERINE  LIGAMENTS 

Diagnosis  of  congenital  anomalies  of  the  uterus,  p.  197:  I.  Anomalies  due 
to  arrest  of  development,  p.  198 :  Absence  of  the  uterus,  p.  198;  Rudimentary 
uterus,  p.  198;  Uterus  bipartitus,  p.  200;  Uterus  didelphys,  p.  200;  Uterus 
bicornis,  p.  200;  Uterus  septus,  p.  200;  Uterus  unicornis,  p.  200;  Diagnosis, 
p.  201;  Differential  diagnosis,  p.  202.  II.  Anomalies  due  to  arrest  of  growth, 
p.  202:  Infantile  uterus,  p.  202;  Congenital  atrophy,  p.  203;  Puerperal 
atrophy,  p.  203;  Non-puerperal  atrophy,  p.  203. 

Diagnosis  of  laceration  of  the  cervix  uteri,  p.  204:  Anatomy,  p.  204. 
Etiology,  p.  204.  Mechanism  and  pathology,  p.  205.  Results  of  laceration, 
p.  206:  Subinvolution,  p.  207;  Diagnosis  of  laceration,  p.  208:  Recent 
lacerations,  p.  208;  Old  lacerations,  p.  209.  Differential  diagnosis,  p.  210. 

Diagnosis  of  the  diseases  of  the  uterine  ligaments,  p.  210:  The  broad 
ligaments,  p.  21 1 :  Parovarian  cysts,  p.  211 ;  Varicocele  of  the  broad  ligament, 
p.  212.  The  round  ligaments,  p.  212:  Tumors,  p.  212;  Hydrocele  of  the 
canal  of  Nuck,  p.  213.  The  utero-sacral  ligaments,  p.  213.  The  utero- 
ovarian  ligaments,  p.  214. 

CERTAIN  points  in  the  anatomj'-  and  mechanics  of  the  uterus  have 
been  considered  in  Chapter  V.,  page  44,  and  others  will  be 
described  in  Chapter  XIV.,  on  the  diagnosis  of  malpositions  of  the 
uterus,  pages  222-224.  The  endometrium^  has  been  described  in 
Chapter  XL  on  Endometritis,  page  166.  In  the  present  chapter  we 
will  take  up  the  arrests  of  development,  lacerations  of  the  cervix, 
and  diseases  of  the  uterine  ligaments. 


DIAGNOSIS  OF  CONGENITAL  ANOMALIES  OF  THE  UTERUS 

The  uterus,  which  in  the  virgin  measures  three  inches  in  length, 
two  inches  in  breadth  at  the  fundus,  and  nearly  an  inch  in  thickness, 
is  developed  from  the  coalescence  of  the  two  Mullerian  ducts  in 
the  embrvo.  This  coalescence  takes  place  from  the  eighth  to 
the  twelfth  weeks  of  fetal  life.  The  development  should  be  com- 
plete, with  the  septum  between  the  two  ducts  absorbed  and  the 

107 


198 


CONGENITAL   ANOMALIES   OF   THE   UTERUS 


uterus  completely  formed,  by  the  twentieth  week,  and  after  this 
time  the  question  is  one  of  growth,  and  not  of  development.  The 
period  of  growth  extends  to  the  twentieth  year  of  life.  Therefore, 
in  seeking  the  cause1  of  uterine  anomalies  we  have  to  consider  two 
factors — arrested  development  and  arrested  growth. 


Vyrifja.1  portion 
--UrogfntleiL  Sinus. 


FIG.  71. — The  Development  of  the  Tubes.  Uterus  and  Vagina  in  the  Fetus. 
The  Vaginal  Portions  of  the  Miillerian  Ducts  Are  Here  Still  Separate.  (After 
.1.  Kollmann.) 

I.  ANOMALIES   DUE  TO  ARREST   OF   DEVELOPMENT 

Absence  of  the  Uterus. — Complete  absence  of  the  uterus,  i.e., 
those  cases  in  which  there  is  present  not  even  a  knob  of  tissue  at 
the  upper  end  of  the  vagina  to  represent  a  uterus,  is  an  affair  only 
of  non-viable  fetal  monstrosities  or  pseudo-hermaphrodites. 

Rudimentary  Uterus. — Rudimentary  uterus,  on  the  other  hand, 


ANOMALIES  DUE  TO  ARREST  OF  DEVELOPMENT 


199 


is  not  so  uncommon.  A  goodly  number  of  cases  have  been  re- 
ported in  the  literature  and  they  generally  appear  under  the  caption 
of  "absence  of  the  uterus"  because  the  diagnosis  is  so  difficult 
during  life.  In  these  cases  there  is  present,  in  the  situation  usually 
occupied  by  the  uterus,  a  knob  of  connective  tissue  of  variable 


FIG.  72. — Uterus  Bipartitus. 


FIG.  73.— Uterus  Didelphys. 


FIG.   74. — Uterus  Bicornis. 


FIG..  75. — Uterus  Septus. 


Fie;.    70. — Uterus  Unicornis. 


FIG.   77. — Uterus     Unicornis    with 
Accessory    Cornu. 


size  and  there  is  partial  or  complete  absence  of  the  vagina.  The 
tubes  are  absent  and  the  ovaries  may  or  may  not  be  absent.  If 
they  are  present  the  patient  suffers  from  molimina.  Patients  with 
this  abnormality  of  development  are  generally  well-formed  women 
with  normal  external  genitals,  breasts,  hair,  and  voice,  who  consult 


CONGENITAL    ANOMALIES   OF   THE    UTERUS 

the  physician  because  of  the  absence  of  menstruation.  The  case 
of  a  married  woman  reported  by  me, — "Congenital  Absence  of 
Uterus  and  Vagina  "  (Amcr.  Jour,  of  Med.  tici.,  March,  1897), 
came  under  observation  because  of  the  absence  of  a  vagina. 

The  diagnosis  is  made  by  recto-abdominal  examination  with  the 
patient  under  an  anesthetic, — also  by  examination  with  a  large 
sound  in  the  bladder  and  the  finger  in  the  rectum.  An  absolute 
diagnosis  can  be  made  only  by  an  abdominal  section  or  by  a  post- 
mortem examination. 

Uterus  Bipartitus. — Uterus  bipartitus  consists  of  a  poorly  de- 
veloped cervix  continuous  with  two  rudimentary  united  cornua 
which  are  usually  solid  cords,  but  may  be  provided  with  pervious 
canals  as  in  the  figure.  The  ovaries  are  generally  present  in  an 
undeveloped  state.  Here  only  the  lower  part  of  Miiller's  ducts 
have  succeeded  in  coalescing  to  form  a  cervix,  failing  to  unite  in 
their  upper  portions. 

Uterus  Didelphys. — This  is  rare.  It  consists  of  two  separate 
uteri,  each  with  one  horn,  and  two  separate  vagina;.  Sometimes 
the  lower  extremity  of  one  vagina  is  occluded  at  some  point  above 
the  vulva  and  may  contain  retained  secretions.  (See  Congenital 
atresia  of  the  vagina.  Chapter  XX.,  page  357.) 

Uterus  Bicornis. — Uterus  bicornis  is  a  relatively  common  condi- 
tion. In  it  Miiller's  ducts  have  united  to  form  a  cervix  with  two 
canals  and  two  ora,  but  are  ununiied  above,  so  that  there  are  two 
long  cornua  representing  a  uterine  body.  Sometimes  the  union 
has  progressed  to  a  point  a  little  higher  up  in  the  cervix  and  we 
have  one  external  os  and  one  cervical  canal  below,  and  two  cer- 
vical canals  above,  or  the  condition  known  as  Uterus  bicornis  uni- 
collis.  (See  Fig.  78.) 

Uterus  Septus. — Uterus  septus  is  the  coalescence  of  the  ducts 
to  form  a  uterus  which  appears  to  be  normal  externally  but  within, 
its  cavity  is  divided  longitudinally  into  two  cavities  by  a  persist- 
ence of  the  septum. 

Uterus  Unicornis. — Uterus  unicornis  results  from  the  develojv- 
ment  of  only  one  cornu,  the  other  being  entirely  absent  or  rudi- 
mentary. The  corresponding  Fallopian  tube  is  generally  absent. 
If  secretions  accumulate  in  the  rudimentary  cornu,  there  being  no 
outlet,  a  distended  sac  will  be  formed:  but  fortunately  this  is  a 
rare  happening.  Pregnancy  may  occur  in  a  rudimentary  horn. 


ANOMALIES  DUE  TO  ARREST  OF  DEVELOPM 


R£ 


also  in  uterus  didelphys,  and,  of  course, 
Chapter  XXIL,  page  433.) 

Diagnosis  of  Uterine  Anomalies  Due  to  Arrest  of  Development.  — 

The  diagnosis  of  uterine  anomalies  due  to  arrest  of  development 
rests  on  the  symptoms  in  the  rare  cases  where  accumulation  of 
secretions  forms  a  sac  that  presses  on  the  bladder  or  rectum,  or 
causes  cramps;  or  cases  in  which  menstruation  does  not  occur  at 
the  normal  age.  As  regards  the  latter  it  should  be  remembered 
that  menstrual  blood  may  flow  from  one  half  of  a  uterus  while  it  is 
collecting  in  the  other  half.  Abortion  and  premature  labor  are 
more  frequent  in  the  case  of  double  uterus,  and  the  presence  of  a 
septum  makes  delivery  difficult  and  involution  slower.  A  decidua 


FIG.  78. — Bicornute  Uterus,  One  External  Os,  Two  Uterine  Cavities.  Removed 
from  Single  Woman  31  Years  old,  Jan.  27,  1903,  for  Rebellious  Dysmenorrhea. 

forms  in  the  empty  half  of  a  septate  pregnant  uterus  or  in  a  rudi- 
mentary horn  just  as  it  forms  in  the  uterus  in  the  case  of  tubal 
pregnancy. 

By  examination  the  presence  of  two  vaginal  canals  is  a  definite 
indication  of  a  double  uterus.  If  the  vagina  is  single  the  two  ora 
of  a  didelphys  uterus  may  be  palpated  by  the  examining  finger 
and  may  be  seen  through  the  speculum.  Two  uterine  horns,  or  a 
divided  fundus,  may  be  felt  by  bimanual  examination  if  the 
conditions  are  exceptionally  favorable,  that  is,  a  thin  and  lax 
abdominal  wall  and  absence  of  much  fat.  If  the  uterus  feels 
normal  to  the  bimanual  palpation  except  for  the  presence  of  two 
ora  in  the  cervix,  two  sounds  are  passed  simultaneously,  one  into 
each  os,  and  an  attempt  made  to  make  them  meet  in  the  uterus. 


1202  roXCIKMTAL   AXO.MALIKS   OF   TIIK   UTERUS 

I.f  they  (In  net  meet,  the  case  is  one  of  uterus  scptus.  If  the  sep- 
tum docs  not  reach  to  the  external  os  the  diagnosis  is  more  diffi- 
cult, and  in  this  case  the  lower  edge  of  the  septum  may  possibly 
be  felt  with  the  tip  of  the  sound.  If  the  bimanual  touch  shows 
that  there  is  a  depression  in  the  fundus  we  have  to  do  with  a  case 
of  uterus  didelphys  or  uterus  bicornis,  the  latter  being  much  more 
frequent.  The  halves  of  a  uterus  bicornis  are  commonly  closely 
adherent  well  above  the  level  of  the  internal  os  and  can  not  be 
moved  independently,  whereas  in  the  case  of  uterus  didelphys 
the  two  halves  are  well  separated  and  can  be  so  moved.  They 
may  lie  even  at  some  distance  from  each  other,  and  the  point  of 
separation  may  be  felt  by  rectal  palpation,  and  if  the  conditions 
for  palpation  are  favorable,  an  ovary  attached  to  each  horn  may  be 
palpated. 

The  diagnosis  of  the  one-horned  uterus  is  not  easy.  The  fundus 
is  found  to  one  side  of  the  pelvis,  it  is  tapering,  and  only  one  ovary 
can  be  made1  out.  Hematometra  or  pyomctra  may  be  present, 
and  are  to  be  diagnosed  as  swellings  occupying  a  portion  of  the 
uterus.  The  diagnosis  is  difficult  and  is  seldom  made  exactly 
without  opening  the  abdomen. 

Differential  Diagnosis. — It  is  important  to  distinguish  pregnancy 
in  a  detached  cornii  of  an  anomalous  uterus  from  a  fibroid  tumor. 
The  occurrence  of  irregular  hemorrhage  from  the  uterus  and  the 
absence  of  the  signs  and  symptoms  of  pregnancy,  together  with 
hardness  and  irregularity  of  the  surface  of  the  tumor,  serve  to 
point  toward  a  fibroid. 

II.  ANOMALIES  DUE  TO  ARREST  OF  GROWTH 

These  are  infantile  or  puerile  uterus,  in  which  the  uterus  of  the 
adult  remains  of  the  type  found  at  birth, — and  congenital  atrophy 
of  the  uterus,  in  which  the  organ,  though  of  the  type  of  the  adult, 
is  atrophied  as  a  whole.  These  two  sorts  of  malformations  are 
not  very  uncommon.  The  condition  known  as  rctroposition  with 
anteflexion  (see  page  2.'>1)  would  seem  to  be  closely  allied  to  the 
infantile  uterus. 

Infantile  Uterus. — This  is  a  relatively  common  condition.  The 
infantile  uterus  is  narrow  in  proportion  to  its  length,  has  a  long 
cervix  and  a  short  body,  and  the  uterus  is  situated  well  back  and 


ANOMALIES  DUE  TO  ARREST  OF  GROWTH  203 

high  In  the  pelvis  at  the  end  of  a  long  vagina,  there  being  at  the 
same  time  more  or  less  anteflexion.  The  os  is  a  "pinhole  os"  and 
the  cervix  is  conical.  Menstruation  is  usually  absent  in  these  cases, 
but  the  breasts,  figure,  hair,  and  voice  may  be  perfectly  normal; 
sexual  desire  is  absent  and  the  patient  is  necessarily  sterile.  The 
diagnosis  is  made  by  the  bimanual  recto-abdominal  touch  and  by 
passing  the  sound.  The  situation  of  the  internal  os,  where  the  tip 
of  the  sound  or  probe  catches,  is  well  up  in  the  total  length  of  the 
uterus  and  is  characteristic,  and  the  relatively  large  and  long 
cervix,  and  short  and  slender  body,  can  be  made  out  easily.  The 
ovaries  are  apt  to  be  small  in  these  cases.  Help  in  the  diagnosis 
is  obtained  often  if  the  uterus  is  drawn  down  by  a  tenaculum  held 
by  an  assistant  while  the  bimanual  touch  is  practiced. 

Congenital  Atrophy. — The  congenital  atrophic  uterus  is  a  rare 
condition.  Here  the  diagnosis  is  made  by  finding  a  well-propor- 
tioned uterus  which  is  small  in  all  of  its  diameters.  This  anomaly 
is  associated  with  lack  of  body  growth,  absence  of  pubic  hair  and 
sex  characteristics.  We  must  suppose  that  the  individual  attained 
a  proper  growth  of  the  uterus  to  the  virgin  type  followed  by  atrophy. 
The  condition  has  been/  found  in  dwarfs  and  cretins  and  in  cases  of 
early  tuberculosis  and  chlorosis. 

Puerperal  Atrophy. — The  opposite  of  subinvolution  is  puerperal 
atrophy,  superinvolution.  Vineberg  of  New  York  has  added  to 
our  knowledge  of  lactation  atrophy.  (Amer.  Medico-Surg.  Bull., 
N.  Y.,  1895,  VIII.,  1518.)  It  is  a  shrinking  of  the  uterus  in  size 
symmetrically  below  the  virgin  type,  following  prolonged  lactation, 
and  is  due  probably  to  overstimulation  of  the  uterus  due  to  nursing. 
It  is  not  a  permanent  condition,  the  uterus  returning  to  its  normal 
size  two  or  three  months  after  nursing  has  been  discontinued.  It 
would  appear  that  a  certain  amount  of  atrophy  is  normal  during 
the  puerperium  irrespective  of  lactation,  therefore  superinvolution 
is  a  distinctly  pathological  state. 

Non-puerperal  Atrophy. — This  occurs  even  more  rarely  than 
puerperal  atrophy,,  in  chronic  wasting  diseases,  as  in  tuberculosis, 
and  in  the  acute  infectious  diseases,  such  as  scarlatina.  I  have 
seen  one  case  following  steaming  of  the  uterine  cavity.  Non- 
puerperal  atrophy  may  or  may  not  be  permanent.  The  exact 
causes  are  not  known. 


20-1  LACERATION    OF   THE   CERVIX    UTERI 


DIAGNOSIS  OF  LACERATION  OF  THE  CERVIX  UTERI 

Tlu1  credit  for  a  proper  understanding  of  laceration  of  the  cervix 
uteri  is  due  to  Thomas  Addis  Kmmet.  of  New  York,  who  published 
his  first  paper  on  the  subject,  "Surgery  of  the  Cervix  Uteri/'  in  the 
American  Journal  of  Obstetrics  in  February,  1869.  Previous  to 
this  the  effects  of  lacerations  were  treated  under  the  name  of 
liberations  of  the  womb,  coxcomb  granulations,  or  erosions  of 
various  sorts. 

In  a  large  proportion  of  cases  the  cervix  is  torn  during  labor, 
the  few  cases  where  it  is  injured  by  forcible  dilatation  or  incision 
at  the  hands  of  the  physician  being  disregarded  here,  although  it 
happens  not  at  all  infrequently  that  the  upper  portion  of  the  cervix 
is  injured  by  the  two-branched  steel  dilators  employed  in  dilata- 
tion for  curetting. 

ANATOMY 

The  normal  cervix  in  the  virgin  is  slightly  conical  and  projects 
into  the  vagina  from  a  half  to  five-eighths  of  an  inch  (1  to  1.5  centi- 
meters). The  os  is  round  or  oval  in  shape  and  about  a  sixteenth 
of  an  inch  in  diameter.  In  women  who  have  borne  children  the 
os  is  more  of  a  transverse  slit  (see  Figs.  65  and  06)  and  may  be 
irregular  from  lacerations,  and  the  cervix  is  rounder  and  less  conical 
than  in  the  virgin.  To  the  feel  the  tissues  are  firm,  but  not  hard, 
and  seen  through  the  speculum  are  of  a  yellowish  pink  color. 
The  wall  of  the  cervical  canal  presents  anteriorly  and  posteriorly 
a  longitudinal  column  from  which  proceed  a  number  of  oblique 
columns,  giving  the  appearance  of  branches  from  the  stem  of  a  tree. 
This  is  called  the  uterine  arhor  rita>.  These  columns  become  more 
indistinct  after  the  first  labor,  but  they  are  not  obliterated. 

ETIOLOGY 

The  causes  of  laceration  may  be  enumerated  as:  (1)  A  rapid 
second  stage  of  labor,  (2)  A  large  child  and  a  small  cervix,  ('.]}  A 
rigid  cervix,  as  in  abortion,  or  from  diminished  elasticity  of  the 
tissues,  (4}  Instrumentation,  as  from  the  forceps  or  instruments 
used  in  embrvotomv.  or  in  dilatation,  (5)  Friabilitv  of  the  tissues  of 


MECHANISM  AND  PATHOLOGY 


.205 


the  cervix  clue  to  prolonged  pressure. by  the  presenting  part,  or 
to  disease  of  the  cervix. 


MECHANISM  AND  PATHOLOGY 

In  the  virgin  uterus  the  canal  of  the  cervix  at  its  widest  part, 
i.e.,  midway  between  the  external  os  and  the  internal  os,  is  about 
one-fifth  of  an  inch  in  diameter.  During  delivery  this  must  be 
dilated  to  the  diameter  of  the  child's  head,  some  four  and  a  half 
inches.  The  muscular  fibers  of  the  cervix  become  stretched  ex- 
cessively and  it  is  not  surprising  that  lacerations  occur,  especially 
if  insufficient  time  is  given 
for  the  dilatation.  Lacera- 
tions may  occur  in  any  di- 
rection or  in  several  direc- 
tions, that  is,  they  may  be 
unilateral,  bilateral,  or  stel- 
late, and  anterior  or  poster- 
ior. They  are  most  often 
lateral.  Extensive  tears 
which  involve  the  cervix 
above  the  attachment  of  the 
vagina  are  apt  to  result  in  FIG  79  _Bilateral  Lacerations  of  the  Cer- 
infcction  of  the  perimetric  vix  with  Erosions. 

tissue     (cellulitis).      During 

pregnancy  the  cervix  together  with  the  rest  of  the  uterus  is  enlarged 
to  accommodate  the  growing  fetus.  The  rhythmical  contractions  of 
the  uterus  (luring  the  entire  pregnancy  reach  their  climax  in  labor 
when  the  major  part  of  the  hypertrophied  uterine  muscle  acts  as 
an  expellent  force,  while  the  small  portion  of  the  uterus,  the  lower 
part  of  the  cervix,  acts  a  passive  role  and  is  dilated.  This  lower 
part  of  the  cervix  may  be  likened  to  the  sphincter  ani  muscle. 
After  receiving  an  excessive  stretching  as  a  preliminary  to  an  oper- 
ation for  hemorrhoids,  or  other  operation  on  the  rectum,  the 
sphincter  ani  does  not  recover  its  tone  and  is  unable  to  contract 
for  forty-eight  hours,  more  or  less — in  fact  it  has  been  stretched  for 
this  very  purpose.  So  in  the  ease  of  the  lower  cervix  after  labor. 
It  is  a  flabby,  soft  ring  that  has  no  power  of  contracting.  Under 
normal  conditions,  and  when  not  lacerated,  it  contracts  to  the 


LACERATION    OF   THE   CERVIX   UTERI 


dimensions  of  a  parous,  normal  cervix  in  the  course  of  a  few  days. 
When  torn  the  lips  are  turned  out  into  the  vagina  by  the  weight 
of  the  large  uterus  above  and  the  contracting  power  of  the  cervix 
is  thus  lost.  (See  Fig.  82.)  The  intracervical  tissues  are  everted 
into  the  vagina,  the  uterine  circulation  is  interfered  with,  the  tissues 
become  engorged  and  remain  swollen — therefore  there  is  no  longer 
room  for  them  within  the  uterine  canal.  Infection  of  the  rolled-out 
mucosa  adds  to  the  trouble  and  erosions,  endometritis  and  cystic 
degeneration  result,  with  ultimate  thickening  of  the  torn  lips  from 
subinvolution.  Because  of  the  downward  excursion  of  the  heavy 

uterus  the  cervix'  projects 
relatively  farther  into  the 
vagina  and  the  attachments 
of  the  latter  organ  to  the 
cervix  appear  to  be  higher 
up  on  the  uterus,  although 
in  reality  they  are  not,  and 
thus  the  torn  cervix  seems 
to  be  larger  than  it  is.  Sub- 
involution,  or  chronic  me- 
tritis,  keeps  the  uterus  heavy 
and  in  this  manner  accent- 
uates the  eversion.  Lacer- 
ations of  not  great  extent 

unite  readily  in  the  absence  of  infection.  If  pelvic  inflammation 
is  present  lacerations  are  apt  not  to  heal  so  soon,  if  at  all,  and 
extensive  lacerations  may  involve  the  vagina  and  even  the  bladder 
or  rectum,  leaving  fistula?  behind  them.  It  often  happens  that 
the  laceration  is  in  the  canal  of  the  cervix  and  that  the  external 
os  is  little,  if  at  all,  involved. 


FIG.  80. — Stellate  Lacerations  of  the  Cervix. 


RESULTS  OF  LACERATION 

The  immediate  results  of  laceration  of  the  cervix  are  hemorrhage, 
or  the  production  of  a  fistula.  The  later  results  are  endome- 
tritis,  subinvolution  of  the  uterus,  cystic  degeneration  and  ero- 
sion of  the  cervix  (see  Chapter  XL  on  endometritis,  page  184), 
thus  furnishing  a  favorable  soil  for  the  growth  of  cancer,  cellulitis 


RESULTS  OF  LACERATION 


207 


(see  Chapter  XII.  on  pelvic  inflammation,  page  192),  cicatricial 
stenosis  of  the  uterine  canal,  and  a  tendency  to  sterility  and 
abortion.  As  regards  the  last,  Dr.  Emmet's  tables  (''Principles 
and  Practice  of  Gynecology,"  3rd  edition,  pages  447,  448)  show 
that  following  lacerations  of  the  cervix  71.34  per  cent  of  his  164 
cases  were  sterile,  and  of  the  47  who  became  pregnant,  51  per 
cent  aborted  one  or  more  times.  These  were  in  the  preaseptic 

days  and  infection  as  a  sequence      _      

to  injury  was  undoubtedly  more 
frequent  than  now. 

Endometritis    is    considered    in 
Chapter  XI.,  page  165. 

Subinvolution. — This  may  be  de- 
fined as  a  failure  of  the  physio- 
logical hypertrophy  of  pregnancy 
to  subside  after  labor.  It  is  due 
not  only  to  laceration  of  the  cervix 
but  to  malposition  of  the  uterus 
from  weakening  of  the  uterine 
ligaments  and  too  long  a  stay  in 
bed,  with  general  debility  follow- 
ing confinement.  After  the  early  stages  of  subin volution  infec- 
tion plays  a  role  in  most  cases  and  there  is  present  an  interstitial 
metritis,  formerly  called  areolar  hyperplasia.  In  this  disease  the 
connective-tissue  elements  in  the  uterine  wall  are  increased  and 
the  muscular  elements  diminished.  In  the  acute  stages  there  is  a 
round-celled  infiltration;  the  uterus  is  large  and  feels  softer.  In 
the  later  stages  the  uterus  is  large  but  the  tissues  are  indurated. 
This  is  the  time  when  the  connective-tissue  elements  predominate 
and  a  pathological  involution  takes  place.  The  lymph  and  blood 
vessel.-  are  diminished  in  size,  crowded  out  by  the  connective  tissue; 
the  muscle  atrophies  and  the  uterine  tissues  become  pale  and  in- 
durated. Such  a  state  of  affairs  is  found  in  uteri  which  have 
been  many  years  the  seat  of  chronic  metritis,  not  in  recent  cases, 
i.e.,  generally  not  before  four  or  five  years  after  the  receipt  of 
injury  or  misplacement.  Subinvolution  or  chronic  metritis  may  be 
associated  with  nrterio-sclerosis  of  the  uterine  vessels  in  the  later 
years  of  life. 


FIG.  81. — Crescentic  Lacerations  of 
the  Cervix. 


208 


LACERATIONS   OF   THE   CERVIX    UTERI 


DIAGNOSIS  OF  LACERATION 

The  symptoms  of  laceration  of  the  cervix  are  the  symptoms  of 
the  pathological  conditions  resulting  from  this  lesion.  Immediate 
hemorrhage  following  labor  calls  for  prompt  diagnosis.  The 
specific  nervous  symptoms,  such  as  pain  in  the  suboccipital  region, 
headaches  of  the  vertex  and  neuralgia,  considered  by  Dr.  Emmet 
to  be  due  to  a  ''cicatricial  plug"  in  the  angle  between  the  lips  of 
old  tears  of  the  cervix,  are  now  generally  thought  by  the  profession 

to  be  due  to  a  deterioration  of  the 
nervous  system  caused  by  pelvic 
disease  in  general. 

The  diagnosis  of  lacerations  is  not 
an  easy  matter,  as  becomes  evident 
when  we  reflect  that  the  diagnosis  was 
not  made  until  Emmet  showed  the 
way  in  1862.  The  results  of  lacera- 
tions so  obscure  the  landmarks  that 
at  the  time  when  most  lacerations 
come  under  the  physician's  observa- 
tion— several  years  after  their  receipt 
—he  is  at  a  loss  to  determine  the  exact 
situation  and  extent  of  the  injury. 
(a)  Recent  Lacerations. — In  the  case 
of  recent  tears  of  the  cervix  the  only 
bars  to  an  exact  diagnosis  are  the 
tumefaction  of  the  parts  and  the  exhausted  condition  of  the 
patient.  If  there  is  excessive  hemorrhage  following  delivery  the 
diagnosis  must  be  made  at  once.  In  other  cases  it  may  be  made 
in  a  few  hours  or  days,  depending  on  the  patient's  condition.  The 
woman  should  be  in  the  dorsal  position  on  a  table  in  a  good 
light.  The  perineum  being  retracted  by  a  large  Sims  speculum 
in  the  hands  of  an  assistant,  the  cervix  is  sei/ed  with  a  double 
tenaculum  and  drawn  down  and  search  is  made  for  solution  in 
continuity  in  the  circle  of  the  enlarged  os.  Tears  can  be  repaired 
at  this  tirie  by  suturing.  Some  operators  prefer  to  do  this  in 
an  intermediate  time,  i.e.,  four  or  five  days  after  labor,  perhaps 
scraping  the  edires  of  the  tear  with  sterile  <:au/e  before  uniting 


FIG.  82. — Diagram  Showing 
Bilateral  Laceration  of  the  Cer- 
vix with  Eversion  of  the  Lips. 


DIAGNOSIS  OF   LACERATION 


209 


them.  The  injuries  must  be  followed  carefully  to  their  limits, 
whether  they  be  confined  to  the  cervix,  or  if  they  extend  to  the 
vagina,  or  even  to  the  rectum  or  the  bladder. 

(6)  Old  Lacerations.  —  If  every  woman  were  submitted  to  a 
careful  uterine  examination  after  child-bearing,  and  injuries  of  the 
cervix,  as  well  as  those  of  the  pelvic  floor,  found  and  repaired,  there 
would  be  comparatively  little  for  the  gynecologist  to  do.  It  hap- 
pens, however,  that  most  of  the  lacerations  of  the  cervix  come 
under  the  physician's  notice  for  the 
first  time  some  years  after  their  re- 
ceipt. At  this  time  the  diagnosis  is 
difficult  because  of  enlargement  and 
distortion  of  the  cervix,  eversion  of 
the  lips,  and  cystic  degeneration  of 
the  Nabothian  follicles  and  erosion. 
The  trained  vaginal  touch  after  a  little 
practice  detects  all  of  these  features 
even  to  the  erosion.  For  inspection 
the  Sims  position  is  best.  Search  first 
for  the  arbor  vitaB  and  thus  deter- 
mine the  situation  of  the  cervical 
canal.  The  passage  of  the  sound 
helps  to  define  the  situation  of  this 
canal,  but  the  physician  must  be  on  FIG.  83.— Unilateral  Lacera- 
his  guard  not  to  be  misled  by  the  tions  of  the  Cervix,  Producing 
malpositions  of  the  uterus  found  in  Obliquity  of  the  Long  Axis  of  the 

Uterus.      (After   Emmet.)      The 

cases  of  unilateral  tear    as    pointed  Reduplication  of  the  Vagina  is 
out  by  Emmet.     (See  Fig.  83.)    In  shown  at  W. 
this   event  the  sound   passed   to  the 

cornu  opposite  to  the  seat  of  the  laceration  may  appear  to  be  in 
the  canal  (see  figure),  but  because  of  the  tilting  of  the  fundus 
toward  the  laceration  the  sound  occupies  the  laceration  and  not 
the  normal  cervical  canal.  Here  a  search  for  the  arbor  vitse  will 
help  to  set  us  right  and  the  bimanual  touch  will  also  assist. 
Putting  the1  patient  in  the  knee-chest  position,  thus  permitting 
the  uterus  to  fall  toward  the  abdomen  high  in  the  pelvis,  straightens 
its  axis  and  also  pulls  out  the  reduplication  of  the  vagina  on  the 
side  where  the  laceration  is  situated.  In  all  lacerations  of  severe 
grade  it  is  well  to  study  the  conditions  as  seen  through  the  specu- 
14 


210  DISEASES  OF  THE  UTERINE  LIGAMENTS 

him  when  the  patient  is  in  this  position,  because  in  the  dorsal 
position  the  weight  of  the  uterus — usually  increased  in  cases  of 
laceration — drives  this  organ  downward  so  that  the  intravaginal 
portion  of  the  cervix  seems  to  be  longer,  especially  if  the  upper 
vagina  has  become  stretched.  Therefore,  there  is  present  in  ex- 
tensive lacerations  of  the  cervix  apparent  hypertrophy  and  elon- 
gation of  the  cervix  beyond  what  really  exists.  This  reduplication 
of  the  vagina  is  shown  at  X  in  the  figure.  Next,  with  the 
patient  in  the  Sims  position,  hook  a  tenaculum  into  the  crown  of 
each  lip  of  the  cervix  and  bringing  the  two  tenacula  together, 
try  to  reconstruct  the  cervix.  If  there  is  much  induration  of  the 
tissues  this  feat  is  difficult  of  accomplishment.  By  palpation  with 
the  tip  of  the  finger  or  the  sound,  determine  the  situation  and  extent 
of  cicatricial  tissue  in  the  angle  of  the  tear,  pressure  on  the  tissue 
causing  pain.  With  the  tip  of  the  sound  a  laceration  within  the 
canal  of  the  cervix  may  be  appreciated,  for  in  that  situation  the 
sound  falls  into  an  opening  in  the  otherwise  smooth  mucosa  of 
the  wall  of  the  canal.  The  internal  os  will  be  found  abnormally 
large  should  the  laceration  involve  this  region,  permitting  the  sound 
to  be  moved  freely  about  after  it  has  been  passed  through. 
"When  the  arbor  vita?  has  been  made  out  the  situation  of  the 
laceration  with  reference  to  it  is  determined. 

DIFFERENTIAL  DIAGNOSIS  OF  LACERATIONS 

Cancer  of  the  cervix  is  the  disease  most  often  mistaken  for  lacer- 
ated cervix.  The  differential  diagnosis  is  considered  under  cancer 
of  the  cervix,  Chapter  XVI,  page  272.  Carcinoma  is  attended  by 
much  induration  of  the  tissues  and  ulceration,  also  cancer  bleeds 
easily  and  the  superficial  portions  are  friable.  Endocervicitis  and 
erosion  is  a  coincident  condition  in  laceration,  but  may  exist  in 
the  absence  of  laceration.  The  diagnosis  is  based  on  the  absence 
of  the  signs  of  laceration.  Eversion  of  the  mucous  membrane  of 
the  cervical  canal  may  be  present  without  laceration  and  it  is  well 
to  bear  this  fact  in  mind.  The  cervix  in  such  cases  is  of  normal 
contour  and  there  are  no  evidences  of  laceration. 

DIAGNOSIS  OF  DISEASES  OF  THE  UTERINE  LIGAMENTS 

The  uterine  ligaments  are  the  broad  ligaments,  the  round  liga- 
ments, the  utero-sacral  ligaments,  and  the  utcro-ovarian  ligaments. 


THE   BROAD   LIGAMENTS  211 


THE  BROAD  LIGAMENTS 

These  become  stretched  in  prolapse  of  the  uterus  so  that  they  no 
longer  support  that  organ.  Under  normal  conditions  they  have 
enough  elasticity,  together  with  the  utero-sacral  ligaments,  to  re- 
store the  uterus  to  its  normal  situation  after  it  has  been  drawn 
down  forcibly.  Certain  tumors  originate  in  the  broad  ligaments, 
notably  parovarian  cysts,  fibromata  and  lipomata,  also  dilatation 
of  the  veins,  varicocele.  The  solid  tumors  are  extremely  rare, 
lipomata  are  seldom  seen,  and  fibromata  only  occasionally,  the  lat- 
ter being  not  large  as  a  rule  and  arising  in  the  unstriped  muscle  fiber 
between  the  folds  of  the  ligament.  Sarcoma  and  carcinoma  of  the 
broad  ligament  are  secondary  to  malignant  disease  of  the  uterus. 

Parovarian  Cysts. — These  originate  in  Gartner's  duct,  Kobelt's 
tubules,  or  in  the  parovarium  proper.  Small  pedunculated'  cysts 
may  develop  from  one  of  these  structures,  or  the  cysts  may  be 
sessile  and  large.  These  large  cysts,  so  called,  develop  between  the 
layers  of  the  broad  ligament  and  are  of  slow  growth.  They  are 
seldom  larger  than  a  child's  head.  The  cyst  has  no  pedicle,  the 
Fallopian  tube  is  stretched  over  its  surface,  and  the  cyst  pushes  the 
uterus  to  the  opposite  side  of  the  pelvis.  Adhesions  are  rare  be- 
cause the  cyst  is  covered  by  peritoneum.  The  wall  of  the  cyst  is 
thin,  transparent,  and  of  a  greenish-yellow  hue,  the  contents  are  a 
thin,  colorless  fluid  of  a  non-irritating  character  having  a  specific 
gravity  of  1002  to  1008.  Upon  rupture  the  cyst  is  apt  not  to  refill, 
in  this  respect  differing  from  an  ovarian  cyst.  A  parovarian  cyst 
may  be  rarely  the  seat  of  papilloma  and  in  this  case  the  contents 
are  opaque,  the  walls  are  thick,  and  the  cyst  is  like  a  papillomatous 
cystoma  of  the  ovary.  The  diagnosis  is  made  by  vagino-abdominal 
and  recto-abdominal  palpation,  if  necessary  having  the  uterus 
drawn  down  by  a  vulscllum  while  the  palpation  is  being  practiced. 
(See  Fig.  12o,  page  294.)  The  cyst  is  on  one  side  of  the  pelvis,  in 
close  relation  with  the  uterus.  Its  mobility  is  distinctly  limited; 
it  is  ovoid  in  shape  and  has  smooth  walls;  fluctuation  is  distinct, 
being  felt  through  the  vault  of  the  vagina;  there  is  no  pedicle,  but 
a  groove  between  the  cyst  and  the  uterus  can  be  distinguished. 
The  differential  diagnosis  is  considered  in  Chapter  XVII,  on 
ovarian  tumors,  page  297. 


212  DISEASES  OF  THE  UTERINE  LIGAMENTS 

Varicocele  of  the  Broad  Ligament. — This  is  not  a  very  rare  disease. 
It  consists  of  dilated  veins  running  transversely  in  the  upper  part 
of  the  broad  ligament  and  forming  a  tumor  that  may  he  as  large  as 
a  small  hen's  egg,  though  generally  much  smaller.  Yaricocele  is 
found  more  often  on  the  left  side.  Perhaps  this  is  because  the  left 
ovarian  vein  is  valveless  and  opens  into  the  renal  vein  at  a  right 
angle.  It  is  possible  to  make  a  diagnosis  by  recto-abdominal  palpa- 
tion by  finding  a  doughy-feeling  tumor  in  the  broad  ligament,  but  as 
such  a  tumor  is  not  tense  except  when  the  patient  is  in  the  erect 
posture,  the  diagnostician  would  be  likely  to  miss  it  during  the 
usual  examination  made  with  the  patient  in  the  dorsal  position. 
If  there  are  varicosities  elsewhere  in  the  body  varicocele  of  the 
broad  ligament  should  come  into  the  physician's  mind  and  he 
should  examine  the  patient  in  the  standing  position.  The  char- 
acteristic symptom  of  varicoccle  of  the  broad  ligament  is  a  dull 
aching  pain  in  the  pelvis  or  back. 

THE  ROUND  LIGAMENTS 

The  round  ligaments  vary  much  in  size  and  in  length  in  different 
individuals,  therefore  their  ability  to  steady  the  uterus  as  guys  is  a 
variable  quantity.  The  muscular  fibers  are  situated  in  the  inner 
two-thirds  of  the  ligament  and  sometimes  the  ligaments  are  nothing 
but  the  slenderest  of  cords.  Fibroma,  fibromyoma,  adenomyoma, 
fibromyxoma,  and  sarcoma  of  the  round  ligament  have  been  de- 
scribed. The  tumor  is  generally  unilateral  but  may  be  bilateral. 
These  tumors  arc1  thought  by  some  writers  to  be  associated  with 
fibroids  of  the  uterus.  They  may  be  found  in  any  portion  of  the 
course  of  the  ligament. — in  the  abdominal  cavity,  the  inguinal 
canal,  or  in  the  labium  majus, — and  they  develop  slowly,  but  may 
be  stimulated  to  more  rapid  growth  by  the  presence  of  pregnancy. 
The  tumors  are  hard  and  generally  pedunculatcd. 

Diagnosis  of  Tumors  of  the  Round  Ligament. — If  a  tumor  is  situ- 
ated within  the  peritoneal  cavity  it  is  felt  by  bimanual  palpation 
in  the  front  of  the  pelvis  on  one  side.  If  it  is  in  the  inguinal  canal 
or  labium  majus  the  tumor  is  felt  from  the  outside  in  the  course  of 
the  canal  or  in  the  labium.  It  must  be  differentiated  from  omental 
or  ovarian  hernia,  hydrocele  of  the  round  ligament,  a  cyst  of  Bar- 
tholin's  gland,  or  enlarged  inguinal  lymphatic  glands.  There  is  no 


THE  UTERO-SACRAL  LIGAMENTS  213 

impulse  on  coughing  or  straining  and  the  enlargement  can  not  be 
reduced  by  taxis.  An  ovary  in  the  inguinal  canal  is  very  sensitive 
to  pressure,  and  swells  and  is  painful  at  the  time  of  menstruation. 
A  cyst  of  Bartholin's  gland  will  present  fluctuation,  and  enlarged 
inguinal  glands  are  generally  separate  glands,  i.e.,  they  are  multiple 
tumors  and  are  situated  to  the  outside  of  the  inguinal  canal. 

Hydrocele  of  the  Round  Ligament  or  of  the  Canal  of  Nuck. — In  the 
fetus  the  peritoneal  covering  of  the  round  ligament  projects  as  a 
tubular  process  into  the  inguinal  canal.  This  tube  is  called  the 
Canal  of  Nuck  and  it  sometimes  persists  through  life.  If  fluid 
collects  in  this  canal  and  the  abdominal  end  of  the  canal  is  oblit- 
erated there  is  found  a  cystic,  translucent,  oval  tumor  which  may 
extend  downward  even  into  the  labium  majus.  In  size  the  tumor 
may  be  as  large  as  a  hazelnut  or  even  attain  the  proportions  of  a 
cocoanut.  It  can  not  be  pushed  up  into  the  abdomen,  it  fluctuates, 
and  has  an  impulse  on  coughing  if  situated  in  the  inguinal  canal. 
In  rare  cases  the  cystic  tumor  may  communicate  with  the  peri- 
toneal cavity  ami  in  this  event  the  fluid  may  be  forced  out  of  it  by 
gentle  pressure.  Hydrocele  is  not  tender  like  an  ovarian  hernia; 
it  is  of  gradual  development  and  often  there  is  difficulty  in  distin- 
guishing a  hydrocele  from  hernia.  In  the  case  of  encysted  hydro- 
cele  the  elastic,  translucent  character  of  the  tumor  that  can  not 
be  reduced  with  the  patient  recumbent,  serves  to  distinguish  it. 
The  hydrocele  that  connects  with  the  peritoneal  cavity  can  not  be 
differentiated  from  hernia  without  an  operation.  In  the  case  of  an 
inflamed  hydrocele  the  differentiation  from  a  strangulated  hernia 
is  made  by  the  absence  of  severe  constitutional  symptoms,  and 
of  symptoms  of  intestinal  obstruction.  As  a  matter  of  fact  such 
tumors  have  generally  been  operated  on  for  strangulated  hernia. 

THE  UTERO-SACRAL  LIGAMENTS 

The  utero-sacral  ligaments  contain,  besides  connective  tissue 
and  peritoneum,  as  do  the  round  ligaments,  a  certain  amount 
of  muscle  fillers.  When  the  uterus  is  drawn  down  forcibly  there 
is  elasticity  enough  in  the  ligaments  to  pull  the  uterus  back  again. 
The  ligaments  are  much  overstretched  in  prolapse  of  the  uterus 
and  are  abnormally  short  in  retroposition  with  anteflexion,  in  the 
latter  case  being  almost  of  a  cicatricial  hardness.  Naturally  liga- 


214  DISEASES  OF  THE  UTERINE  LIGAMENTS 

merits  of  this  character  limit  the  downward  or  forward  excursion 
of  the  uterus.  The  diagnosis  of  shortening  is  made  by  the  bi- 
manual  vagino-abdominal  and  recto-abdominal  touch.  The  uterus 
is  raised  and  at  the  same  time  the  ligaments  are  palpated  to  detect 
shortening  and  thickening,  or  the  uterus  is  brought  down  by  trac- 
tion with  a  tenaculum  while  the  rectal  touch  is  practiced.  Short- 
ened ligaments  are  easier  to  make  out  than  lengthened  ones.  In 
the  infant,  the  uterus  being  very  high  in  the  pelvis,  the  utero- 
sacral  ligaments  course  from  their  origins  at  the  second  piece  of 
the  sacrum  to  their  insertions  on  the  uterus  in  the  form  of  an  arch 
and  may  be  felt  in  this  shape  by  rectal  palpation.  The  operator 
should  not  lose  the  opportunity  afforded,  during  abdominal  opera- 
tions when  the  cul-de-sac  of  Douglas  is  in  view,  to  inspect  as  well 
as  to  palpate  these  ligaments  from  above. 

THE  UTERO-OVARIAN  LIGAMENTS 

The  following  tumors  have  been  found  in  these  ligaments: 
fibroma,  sarcoma,  and  carcinoma.  The  last  two  must  be  regarded 
as  extensions  of  the  disease  from  the  uterus;  the  former,  fibroma, 
is  very  rare.  These  tumors  can  not  be  distinguished  from  ovarian 
tumors  without  opening  the  abdomen.  In  some  cases  the  ovarian 
ligaments  are  very  long,  thus  favoring  prolapse  of  the  ovaries. 


CHAPTER  XIV 

THE  DIAGNOSIS  OF  MALPOSITIONS  OF  THE  UTERUS 

General  considerations,  p.  215. 

I.  Malpositions  of  the  uterus  as  a  whole,  p.  218:    1.  Ascent,  p.  218.     2. 
Descent  (prolapse),  p.  218;   Pathology,  p.  218;  Mechanism,  p.  219;   Symp- 
toms and  course,  p.  226;    Diagnosis,  p.  226;    Differential  diagnosis,  p.  228. 
3.  Anteroposition,  p.   229.      4.  Lateroposition,  p.    229.      5.  Retroposition, 
p.  230:   Retroposition  with  anteflexion,  p.  231;    Diagnosis  of    retroposition 
with  anteflexion,  p.  232.   6.  Hernia  of  the  uterus,  p.  233. 

II.  Abnormalities  of  the  axis  and  form  of  the  uterus,  p.  234:    1.  Retro- 
version,  p.  234:  Retroversio-flexion,  p.  234;  Diagnosis  of  retroversio-flexion, 
p.  236.     2.  Anteversion,  p.  238.     3.  Anteflexion,  p.  240.     4.  Inversion,  p. 
240;     Diagnosis,  p.  240;   Differential  diagnosis,  p.  240.     5.  Torsion,  p.  243. 

GENERAL  CONSIDERATIONS 

IN  considering  the  subject  of  malpositions  of  the  uterus  it  must 
be  understood  that  displacement  of  the  uterus  carries  with  it  more 
or  less  change  in  the  position  of  other  pelvic  organs  at  the  same 
time.  For  instance,  it  is  manifestly  impossible  to  place  the  uterus 
in  a  condition  of  complete  prolapse  without  altering  the  position 
of  the  tubes,  ovaries,  bladder,  and  vagina. 

We  shall  consider  in  each  instance  the  dislocation  of  the  most 
important  organ,  noting  the  complications.  The  normal  position 
of  the  uterus  and  the  factors  which  determine  its  situation  in  the 
pelvis  and  limit  its  mobility  under  the  varying  conditions  of  health 
have  been  described  in  Chapter  V.,  page  43. 

When  pregnant  or  under  conditions  of  disease  the  uterus  is  sub 
ject  to  certain  displacements  as  a  whole,  and  its  long  axis  may  be; 
turned  or  verted  in  one  of  several  directions.  Theoretically  we 
have  to  do  with  two  distinct  classes  of  displacements.  The  uterus 
may  be  likened  to  a  telescope  upon  a  stand  in  a  room.  The  tele- 
scope may  be  in  the  middle  of  the  room  (the  pelvis),  or  it  may  be 
placed  against  the  wall  (retro-position),  or  it  may  be  raised  (ascent), 
or  lowered  (prolapse).  Also  it  may  be  tilted  in  one  of  many  direc- 

215 


210 


MALPOSITIONS  OF  THE  UTERUS 


tions  (version)  although  its  position  as  a  whole  with  reference  to 
the  walls,  floor,  and  ceiling  of  the  room  has  not  been  changed. 

Alteration  of  the  position  of  the  uterus  generally  but  not  neces- 
sarily implies  change  in  its  axis,  and  often  in  its  form.  For  in- 
stance, retroversion  generally  means  a  certain  degree  of  retro- 
position  and  often  retrofiexion ;  prolapse  presupposes  retroversion 


FIG.  84. — Median  Section  of  the  Body  of  a  Woman  Who  has  Borne  Children. 
Bladder  Empty.     (Schullze.)    Note  Anteversion  of  Uterus. 

in  the  early  stages  of  the  descent  of  the  uterus;  inversion  is  a  form 
of  prolapse1. 

The  lesion  that  is  supposed  to  be  the  important  one  from  a 
pathological  standpoint  gives  the  name  to  the  displacement,  al- 
though— as  before  stated — several  lesions  are  involved.  The 
classification  hero  used  is  a  practical  rather  than  a  theoretical  one. 

In  describing  the  pelvic  circulation.  Chapter  V.,  page  46,  it  has 
been  stated  that  the  blood-vessels  of  the  uterus  and  broad  liga- 
ments are  convoluted,  valveless,  and  capable  of  great  distention, 
depending  for  their  normal  tone  on  absence  of  constricting  infill- 


GENERAL  CONSIDERATIONS 


217 


ences  in  the  way  of  pressure  from  tumors  or  pelvic  inflammatory 
masses,  or  stretching  due  to  malposition  of  the  uterus. 

We  know  how  much  a  prolapsed  uterus  is  reduced  in  size  after 
it  has  been  replaced  in  a  normal  position  in  the  pelvis  and  main- 
tained there  for  a  few  hours  even.  We  know  that  a  normal  uterus, 
displaced  downward  mechanically,  becomes  congested.  It  is  fair 
to  assume  that  this  is  due  to  a  straightening  of  the  tortuous  valve- 


~-.- 


FIG.    84o. — Longitudinal  Median  Section  of   a  Pelvis  with  Overdistended  blad- 
der.    (,Zuckerkandl.)      Note  Retroversion  of  Uterus. 

loss  veins,  thus  lessening  the  resistance  of  their  walls  to  an  in- 
creased pressure  delivered  by  the  less  convoluted  arteries. 

It  is  the  view  of  the  author  that  uterine  malpositions  have  a 
direct  mechanical  effect  on  the  pelvic  circulation,  therefore  dis- 
placements of  the  uterus  as  a  whole  are  of  more  importance  than 
changes  in  the  axis  (version),  or  changes  in  form  (flexions,  torsions, 
or  tumors). 


21 S  .MALPOSITIONS  OF  THE  UTERUS 


I.  MALPOSITIONS  OF  THE  UTERUS  AS  A  WHOLE 

1.  Ascent.  2.  Descent  (prolapse).  3.  Antero-position.  4.  Latero- 
position.  o.  Retroposition.  6.  Hernia  of  the  uterus. 

1.  ASCENT 

The  uterus  is  in  a  position  of  ascent  in  the  later  months  of  preg- 
nancy; when  it  is  displaced  upward  by  a  tumor  developing  from 
the  lower  part  of  the  pelvis;  when  oversupported  by  a  pessary; 
and  when  it  has  been  attached  to  the  abdominal  wall  by  a  ventral 
suspension  or  fixation  operation.  The  diagnosis  is  established  by 
bimanual  palpation.  The  cervix  uteri  is  far  removed  from  the 
normal  situation  and  in  some  cases  can  not  be  reached  by  the  tip 
of  the  examiner's  finger.  The  fundus  may  be  palpated  through 
the  abdominal  walls.  According  to  our  present  knowledge  ascent 
is  not  an  important  displacement.  The  only  symptom  directly 
traceable  to  ascent  is  an  irritability  of  the  bladder,  seen  occa- 
sionally, and  thought  to  be  due  to  traction  on  the  vesical  neck. 
Prolapse,  on  the  other  hand,  is  extremely  important  as  well  as  of 
common  occurrence. 

2.  DESCENT  OR  PROLAPSE 

The  extent  of  the  descent  varies  from  a  slight  " falling  of  the 
womb"  to  the  complete  escape  of  the  uterus  through  the  vulvar 
orifice. 

When  the  uterus  remains  within  the  body  the  displacement  is 
spoken  of  as  an  incomplete  prolapse,  or  descensus  uteri;  when  it 
is  outside  the  body  it  is  known  as  complete  prolapse,  or  procidentia. 
This  form  of  displacement  is  generally  of  slow  development — a 
matter  of  months  and  years. 

Acute  prolapse,  due  to  violence  or  sudden  straining  when  the 
uterus  is  large  and  heavy,  the  ligaments  weak,  and  the  retentive 
power  of  the  abdominal  walls  diminished — as  after  labor — has 
been  observed  as  a  rarity. 

Pathology. — The  pathology  of  prolapse  includes  the  morbid 
anatomy  of  all  the  pelvic  organs  involved.  The1  circulation  is 
obstructed  by  traction  on  the  vessels  and  all  the  displaced  organs 


DESCENT  OR  PROLAPSE 


219 


become  congested;  the  nerves  also  are  stretched  or  even  sundered. 
The  displaced  vagina  becomes  swollen  and  congested  and  may  be 
ulcerated;  there  may  be  hernia  of  the  cul-de-sac  of  Douglas,  and 
the  rectum  may  occasionally  send  an  offshoot  into  the  hernia; 
the  bladder  is  frequently  displaced  and  is  subject  to  catarrh;  and 
the  endometrium  is  the  seat  of  endometritis — the  uterus  being,  as 
a  rule,  much  congested. 

Mechanism. — To  understand  the  mechanism  of  the  production 
of  prolapse  one  must  consider  three  factors,     (a)  The  pelvic  floor. 
(6)   The  uterine  ligaments  and  attachments  of  the  uterus  to  sur- 
rounding structures,    (c)  The  varia- 
tions   of   pressure   exerted   by   the 
abdominal  contents. 

(a)  The  pelvic  floor  is  a  muscular 
and  tendinous  diaphragm  closing  the 
outlet  of  the  pelvis.  Through  this 
diaphragm  runs  the  vagina  trans- 
versely and  obliquely  as  a  slit.  In 
the  erect  woman  the  vagina  is  at  an 
angle  of  about  60°  with  the  horizon, 
terminating  above  at  the  neck  of  the 
womb,  which  in  turn  has  its  long 
axis  placed  at  a  right  angle  to  the 
long  axis  of  the  vagina. 

The  vagina  in  its  course  from  the 

cervix  to  the  introitus  vaginae  shows  an  S-shaped  curve  when  seen 
in  a  median  longitudinal  section  of  the  body,  the  forward  bulging 
portion  of  the  S  being  in  its  lower  portion  opposite  the  under 
edge  of  the  symphysis  pubis.  (See  Fig.  85.)  This  prominent 
portion  of  the  vagina  is  made  by  the  presence  at  this  point  of 
the  chief  muscle  masses  of  the  levator  ani  and  smaller  muscles 
and  fasciae  making  up  the  pelvic  floor.  It  is  the  so-called  "perineal 
body"  of  the  older  gynecologists.  By  reference  to  the  diagram 
(Fig.  84)  it  will  be  seen  that  this  key-stone  to  the  arch  of  the  pelvic 
diaphragm  lies  about  midway  between  the  lower  border  of  the 
symphysis  and  the  coccyx.  Injury  to  the  muscles  here  naturally 
destroys  the  sigmoid  curve  of  the  vagina,  opens  its  outlet,  and 
diminishes  the  support  to  the  structures  lying  above.  The  vagina, 
instead  of  being  a  flattened  ribbon-like  canal  with  walls  in  apposi- 


FIG.  85. — S-shaped  Curve  and 
Inclination  of  Vagina.  Note  that 
the  Walls  Are  in  Apposition. 

(Skene.) 


220  MALPOSITIONS  OF  THE  UTERUS 

lion  and  running  almost  transversely  from  the  cervix  to  the  hymen, 
now  becomes  a  stniighter  open  tube,  leading  almost  directly  down- 
ward from  the  cervix  to  the  introitus. 

The  pelvic  floor,  according  to  Hart  and  Barbour,  may  be  divided 
up  into  an  anterior  and  a  posterior  segment.  The  anterior  seg- 
ment is  a  relatively  movable  one,  the  posterior  is  relatively  fixed. 
The  anterior  or  pubic  segment  consists  of  anterior  vaginal  wall, 
urethra,  and  bladder,  all  attached  loosely  to  the  symphysis  pubis 
by  retropubic  deposits  of  fat.  The  posterior  or  sacral  segment 
is  made  up  of  posterior  vaginal  wall,  the  muscles  and  fasciae  of 
the  perineum,  and  the  rectum,  all  firmly  bound  to  the  sacrum  and 
coccyx.  During  labor  the  anterior  segment  is  drawn  up;  the 
posterior  segment  is  driven  down.  In  the  formation  of  prolapse 
the  anterior  segment,  because  of  the  injury  of  the  posterior  seg- 
ment, swings  downward  and  backward — the  retropubic  fat  giving 
way  with  consequent  dislocation  of  bladder  and  urethra.  It  is 
plain  that  a  tipping  back  of  the  uterus  on  its  axis,  so  that  it  may 
get  into  the  same  axis  as  the  vagina,  is  a  requisite  to  the  descent 
of  that  organ,  and  that  this  tipping  backward  is  made  possible  by 
injury  of  the  posterior  segment  of  the  pelvic  floor  and  dislocation 
of  the  anterior  segment,  so  that  the  cervix — not  sta}^ed  from  be- 
hind and  having  no  firm  tissue  in  front  of  it— swings  forward  until 
its  long  axis  coincides  with  the  long  axis  of  the  vagina.  This 
subject  will  be  made  clearer  when  we  consider  the  different  direc- 
tions in  which  under  varying  conditions  the  intra-abdominal 
pressure  is  applied  to  the  fundus  uteri. 

(/>)  The  uterine  ligaments  and  the  attachments  of  the  uterus  to 
the  surrounding  structures. 

The  ligaments,  described  in  Chapter  V,  page  44,  consist  of 
three  pairs  of  ligaments  proper — the  broad,  the  round,  and  the 
utero-sacral;  and  the  attachments  are — the  utero-vesical  connec- 
tive tissue,  the  vagina,  and  the  retro-uterine  cellular  tissue.  In 
considering  the  causation  of  prolapse  we  must  think  of  the  woman 
being  in  the  erect  position,  because  it  is  in  this  attitude  that  the 
great  strain  is  brought  to  bear  that  causes  sacro-pubic  hernia. 
By  reference  to  the  diagram  (Fig.  $4)  on  page  21(>  it  will  be  seen 
that  the  origins  and  insertions  of  all  the  ligaments  lie  in  nearly 
the  same  plane.  As  a  matter  of  fact,  the  pubic  ends  of  the  round 
ligaments  are  a  little  lower  than  their  insertions  into  the  horns  of 


DESCENT  OR  PROLAPSE 


221 


the  uterus,  therefore  the  round  ligaments  can  not  support  the 
uterus  except  in  cases  of  extreme  prolapse.  On  the  other  hand, 
the  attachments  of  the  utero-sacral  ligaments  to  the  pelvic  wall 
near  the  second  piece  of  the  sacrum  are  a  trifle  higher  than  their 
insertions  into  the  uterus  at  the  level  of  the  internal  os.  They 
are  normally  firm  and  strong  and  act  as  true  supports. 
The  broad  ligaments  check  lateral  motion  and  limit  the  uterine 


Artefal 
peritoneum. 


aj  planting"  -shflf.  -  - 
Cre-sfof  iliu/r/.^J 


FIG.  86. — Might  Side  of  Abdominal  Wall  Has  Been  Removed,  Showing  Fun- 
nel Shape  of  Abdominal  Cavity,  which  Is  Wide  Above  and  Narrow  Below,  also  the 
Slanting  Shelf  which  (lives  Partial  Support  to  the  Viscera.  (After  Corning.) 

movements  largely  to  forward  and  backward  excursions.  The 
intra-abdominal  pressure- is  exerted  on  the  posterior  aspect  of  their 
broad  surfaces  and  thereby  they  assist  cither  in  retaining  the 
uterus  in  anteversion,  or,  if  the  axis  of  the  uterus  has  been  changed 
from  anteversion  to  retrovcrsion,  the  pressure  being  on  their 
posterior  aspects,  they  assist  in  keeping  the  womb  in  that  position 
and  in  aiding  prolapse.  The  thick  bases  of  the  broad  ligaments 


222  MALPOSITIONS  OF  THE  UTERUS 

intimately  joined  with  the  uterus  form  strong  connecting  and 
supporting  structures  between  the  uterus  and  pelvic  walls.  Pro- 
lapse can  not  occur  unless  the  attachments  of  the  ligaments  or  the 
ligaments  themselves  are  severed  or  stretched.  The  utero-vesical 
connective  tissue,  when  torn  asunder  by  labor  or  when  weakened 
by  the  atrophy  of  the  triangular  mass  of  subpubic  fat,  promotes 
retro  version  and  also  prolapse  by  lessening  the  resisting  power 
of  the  structures  connecting  the  uterus  with  the  symphysis  and 
indirectly  diminishing  the  distance  between  the  cervix  and  the 
pubes. 

One  of  the  common  results  of  a  difficult  labor  is  to  loosen  the 
attachments  of  the  vagina  to  the  cervix.  As  seen  through  a 
speculum  with  the  patient  in  the  Sims  or  knee-chest  position,  there 
appears  to  be  little  or  no  intra-vaginal  portion  to  the  cervix.  In 
these  cases  the  mobility  of  the  uterus  is  increased  and,  other  things 
being  equal,  descensus  is  favored.  The  attachments  of  the  vagina 
to  the  cervix  serve  to  steady  the  uterus  and  keep  it  in  its  proper 
relation  to  the  pelvic  floor. 

The  retro-uterine  cellular  tissue  has  probably  very  little  influ- 
ence on  the  position  of  the  uterus  unless  it  is  the  seat  of  inflamma- 
tory thickening:  in  which  case  it  fixes  the  organ.  It  sometimes 
happens  that  women  who  are  the  subjects  of  pelvic  inflammation 
are  relieved  of  preexisting  prolapse  only  to  suffer  with  it  again 
when  the  exudate  has  been  absorbed. 

(c)  The  variations  of  pressure  exerted  by  the  abdominal  con- 
tents. The  reader  is  referred  to  Chapter  V.,  page  45,  for  a  partial 
exposition  of  this  subject.  Here  it  is  sufficient  to  say  that  we  have 
to  do  with  (1s)  downward  pressure  exerted  by  (a)  increased  weight 
of  the  uterus  itself,  (/>)  the  weight  of  the  intestines  filled  with  a 
varying  amount  of  solid,  fluid,  or  gaseous  matter,  and  (c)  the 
weight  of  dislocated  organs,  such  as  the  stomach  or  kidneys,  or 
the  weight  of  a  tumor;  and  (2)  additional  pressure  transmitted  to 
the  abdominal  contents  by  the  walls  of  the  abdomen  and  by  the 
diaphragm  in  coughing,  laughing,  straining,  jumping,  and  riding. 

The  downward  pressure  spends  itself  under  normal  conditions 
mostly  on  the  lower  anterior  wall  of  the  abdomen.  By  consulting 
Fig.  6,  page  44,  it  is  apparent  that  the  long  axis  of  the  abdominal 
cavity  falls  at  nearly  a  right  angle  to  the  long  axis  of  the  pelvic 
cavity,  and  that  the  pelvic  viscera  are  protected  in  a  measure  from 


223 


pressure  directed  downward  from  above  by  the  forward  lumbar 
curve  of  the  spine,  which,  in  the  normal  standing  posture  of  the 
individual,  must  take  some  of  the  weight  of  the  contents  of  the 
abdomen.  A  transverse  section  of  the  body  of  the  adult  virgin 
through  the  fifth  lumbar  vertebra  shows  that  at  this  situation  the 
depth  of  the  abdominal  cavity  from  before  back  is  very  much  less 
than  it  is  in  the  upper  portion  of 
the  abdomen.  For  instance,  it  rep- 
resents only  a  little  over  a  third 
of  the  entire  thickness  of  the  body 
if  measured  in  the  median  line  from 
the  anterior  face  of  the  lumbar  ver- 
tebra to  the  skin  surfaces  of  the 
front  and  back  of  the  body.  At 
the  level  of  the  twelfth  dorsal  ver- 
tebra, on  the  other  hand,  the 
abdominal  cavity  takes  up  over  a 
half  of  the  thickness  of  the  trunk 
if  measured  in  the  same  way  and 
occupies  a  major  part  of  the  cubic 
contents  of  the  body  at  this  point. 

When  the  back  is  flattened  and 
the  forward  lumbar  curve  is  more 
or  less  obliterated — as  happens  in 
the  case  of  the  flat-chested,  slouchy 
body  post  lire  HO  of  ten  seen  in  women 
— more  of  the  weight  of  the  viscera 
will  fall  on  the  inlet  of  the  pelvis. 

Under   normal   conditions  there 

is  present  a  thrust  directed  forward,  inward,  and  downward  from 
the  slanting  surface  of  the  brim  of  the  false  pelvis  (60°  with  the 
horizon)  that  throws  the  abdominal  pressure  on  to  not  only  the 
lower  abdominal  wall,  but  also  on  to  the  posterior  surface  of  the 
anteverted  uterus  and  the  backs  of  the  wide  expanses  of  the  broad 
ligaments.  Thus  is  the  uterus  maintained  normally  with  its  long- 
axis  at  a  right  angle  at  least  with  the  long  axis  of  the  vagina. 
As  has  been  stated  previously,  the  axis  of  the  uterus  must  be 
changed  to  relroversion  before  prolapse  can  occur.  Such  a  change 
in  axis  is  brought  about  by  relaxation  of  the  uterine  ligaments,  by 


FIG.    87. — Complete   Prolapse    or 
Procidentia.     (After  Huguier.) 


224 


MALPOSITIONS  OF  THE  UTERUS 


chronic  distcntion  of  the  urinaiy  bladder,  chronic  fulness  of  the 
rectum,  sudden  jar,  etc.  (see  Retroversion,  page  234).  When 
once  the  axis  has  been  changed,  the  intra-abdominal  pressure  is  ex- 
erted against  the  anterior  face  of  the  uterus  and  the  broad  liga- 
ments, and  increased  pressure  accentuates  the  retroversion,  and  at 
the  same  time  pushes  down  the  uterus,  now  in  the  same  axis  as 
the  vagina.  Factors  which  make  for  greater  downward  pressure, 
such  as  a  persistent  cough  or  violent  straining  because  of  chronic 


FIG.  88. — Prolapse  of  the  Vagina  and  Cervix,  with  Elongation  of  the  Supra- 
vaginal  Cervix. 

diarrhea,  tend  to  cause  descensus  uteri.  Constant  straining  is  an 
important  factor  in  the  causation  of  prolapse;  therefore  prolapse 
i.s  found  most  frequently  among  women  of  the  working  classes. 
These  women  are  apt  to  get  up  and  begin  work  soon  after  con- 
finement when  the  uterus  is  large  and  heavy  and  retroverted. 

Inversion  of  the  vagina  may  take  place  without  actual  descent 
of  the  uterus  because  of  the  elasticity  of  the  vagina,  and,  prolapse 
may  be  simulated  by  elongation  of  the  lower  uterine  segment. 


DESCENT  OR  PROLAPSE 


225 


True  hypertrophic  elongation  of  the  cervix,  a  lengthening  of  the 
cervix  and  the  lower  segment  of  the  uterus,  is  by  no  means  an 
uncommon  condition.  In  such  a  case,  should  the  utero-sacral 
ligaments,  which  ordinarily  limit  the  amount  of  the  descent  of  the 
uterus,  prove  to  be  strong  and  not  susceptible  of  stretching,  the 
fundus  uteri  may  remain  nearly  at  its  normal  level  while  the  exter- 
nal os  presents  at  the  introitus  vaginse.  A  typical  case  of  true  hyper- 
tropic  elongation  of  the  cervix  was  reported  by  Huguier  ("Memoire 
sur  les  Allongements  Hypertrophiques  du  Col  de  1'Uterus," 


FIG.  88a. — Hypertrophic  Elongation  of  the  Cervix  in  the  Virgin. 

I860,  p.  40)  as  long  ago  as  I860.  A.  woman  twenty-three  years  of 
ago,  of  poor  general  health  and  physique,  married  two  years  but 
never  pregnant,  presented  herself  for  treatment  because  of  pains 
in  the  abdomen,  dyspareunia,  and  a  tumor  in  the  opening  of  the 
vagina.  Catamenia  began  at  thirteen  and  she  noticed  the  pro- 
jection at  the  vulva  at  fourteen  and  a  half  years.  It  came  out 
while  she  was  standing  or  straining  and  was  reduced  on  lying 
down.  Examination  showed  the  vagina  only  a  little  shortened  and 
occupied  by  the  enlarged  cervix;  fundus  uteri  only  a  trifle  below  its 
15 


210 


MALPOSITIONS  OF  THE  UTERUS 


tions  (version)  although  its  position  as  a  whole  with  reference  to 
the  walls,  floor,  and  ceiling  of  the  room  has  not  been  changed. 

Alteration  of  the  position  of  the  uterus  generally  but  not  neces- 
sarily implies  change  in  its  axis,  and  often  in  its  form.  For  in- 
stance, retro  version  generally  means  a  certain  degree  of  retro- 
position  and  often  retroflexion;  prolapse  presupposes  retroversion 


FIG.  84. — Median  Section  of  the  Body  of  a  Woman  Who  has  Borne  Children. 
Bladder  Empty.     (Schultze.)    Note  Anteversion  of  Uterus. 

in  the  early  stages  of  the  descent  of  the  uterus;  inversion  is  a  form 
of  prolapse. 

The  lesion  that  is  supposed  to  be  the  important  one  from  a 
pathological  standpoint  gives  the  name  to  the  displacement,  al- 
though— as  before  stated — several  lesions  are  involved.  The 
classification  here  used  is  a  practical  rather  than  a  theoretical  one. 

In  describing  the  pelvic  eft-dilation,  Chapter  V.,  page1  46,  it  has 
been  stated  that  the  blood-vessels  of  the  uterus  and  broad  liga- 
ments are  convoluted,  valveless,  and  capable  of  great  distention, 
depending  for  their  normal  tone  on  absence  of  constricting  in  flu- 


THE  UTERO-SACRAL  LIGAMENTS  213 

impulse  on  coughing  or  straining  and  the  enlargement  can  not  be 
reduced  by  taxis.  An  ovary  in  the  inguinal  canal  is  very  sensitive 
to  pressure,  and  swells  and  is  painful  at  the  time  of  menstruation. 
A  cyst  of  Bartholiri's  gland  will  present  fluctuation,  and  enlarged 
inguinal  glands  are  generally  separate  glands,  i.e.,  they  are  multiple 
tumors  and  are  situated  to  the  outside  of  the  inguinal  canal. 

Hydrocele  of  the  Round  Ligament  or  of  the  Canal  of  Nuck. — In  the 
fetus  the  peritoneal  covering  of  the  round  ligament  projects  as  a 
tubular  process  into  the  inguinal  canal.  This  tube  is  called  the 
Canal  of  Nuck  and  it  $&metimes  persists  through  life.  If  fluid 
collects  in  this  canal  and  the  abdominal  end  of  the  canal  is  oblit- 
erated there  is  found  a  cystic,  translucent,  oval  tumor  which  may 
extend  downward  even  into  the  labium  majus.  In  size  the  tumor 
may  be  as  large  as  a  hazelnut  or  even  attain  the  proportions  of  a 
cocoanut.  It  can  not  be  pushed  up  into  the  abdomen,  it  fluctuates, 
and  has  an  impulse  on  coughing  if  situated  in  the  inguinal  canal. 
In  rare  cases  the  cystic  tumor  may  communicate  with  the  peri- 
toneal cavity  and  in  this  event  the  fluid  may  be  forced  out  of  it  by 
gentle  pressure.  Hydrocele  is  not  tender  like  an  ovarian  hernia; 
it  is  of  gradual  development  and  often  there  is  difficulty  in  distin- 
guishing a  hydrocele  from  hernia.  In  the  case  of  encysted  hydro- 
cele  the  elastic,  translucent  character  of  the  tumor  that  can  not 
be  reduced  with  the  patient  recumbent,  serves  to  distinguish  it. 
The  hydrocele  that  connects  with  the  peritoneal  cavity  can  not  be 
differentiated  from  hernia  without  an  operation.  In  the  case  of  an 
inflamed  hydrocele  the  differentiation  from  a  strangulated  hernia 
is  made  by  the  absence  of  severe  constitutional  symptoms,  and 
of  symptoms  of  intestinal  obstruction.  As  a  matter  of  fact  such 
tumors  have  generally  been  operated  on  for  strangulated  hernia. 

THE  UTKROSACRAL  LIGAMENTS 

The  utero-sacral  ligaments  contain,  besides  connective  tissue 
and  peritoneum,  as  do  the  round  ligaments,  a  certain  amount 
of  muscle  fibers.  AY  hen  the  uterus  is  drawn  down  forcibly  there 
is  elasticity  enough  in  the  ligaments  to  pull  the  uterus  back  again. 
The  ligaments  are  much  overstretched  in  prolapse  of  the  uterus 
and  are  abnormally  short  in  ret  reposition  with  anteflexion,  in  the 
latter  case  being  almost  of  a  cicatricial  hardness.  Naturally  liga- 


22S  MALPOSITIONS  OF  THE  UTERUS 

of  bladder,  urethra,  and  rectum — also  the  ovaries  and  tubes — 
and  the  amount  of  prolapse;  and  the  condition  of  the  vagina.  In 
most  cases  of  prolapse  the  vagina  becomes  thickened  to  a  marked 
degree  and  takes  on  the  characteristic  of  skin,  and  ulceration  may 
develop  in  its  structures.  These  items  are  to  be  noted  carefully 
because  upon  them  depends  the  form  of  treatment  employed  and 
its  success. 

A  conjoined  recto-abdominal  examination  determines  the  situ- 
ation of  the  fundus  uteri.  A  sound  passed  into  the  uterine  cavity 
shows  its  depth,  size,  and  shape,  and  whether  or  not  any  polypi  are 
situated  there.  The  cleansed  sound  passed  into  the  urethra  shows 
the  direction  of  the  canal  and  whether  any  portion  of  it  is  dislo- 
cated downward  and,  if  so,  how  much.  It  also  shows  the  limits 
of  the  bladder  in  the  prolapsed  mass  by  noting  the  situation  of  the 
point  of  the  sound  on  the  vagina  both  by  sight  and  touch.  (See 
high  light  in  Fig.  89,  marking  tip  of  sound  in  bladder.)  A  finger 
hooked  through  the  anus  shows  whether  the  rectum  has  been  dis- 
located downward.  It  may  be  possible  to  palpate  the  whole  of 
the  uterus  outside  the  vulva  through  the  walls  of  the  inverted 
vagina,  but  in  most  cases,  for  the  purposes  of  diagnosis,  it  is  best  to 
reduce  the  prolapse.  This  is  done  by  covering  it  with  muco- 
lubricans  and  making  gentle  upward  pressure,  at  the  same  time 
squeezing  the  mass  a  little,  and  in  some  cases  it  may  be  necessary 
to  place  the  patient  in  the  knee-chest  position  before  resorting  to 
this  measure.  When  the  mass  has  been  reduced  a  bimanual  ex- 
amination is  made  with  the  patient  in  the  dorsal  position  and  the 
size  and  shape  of  the  uterus  mapped  out  anew.  It  is  now  possible 
to  determine  true  hypertrophic  elongation  of  the  lower  segment 
of  the  uterus,  fibroid  nodules,  the  location  of  the  ovaries,  etc.  If 
the  vaginal  walls  are  much  thickened  the  tactile  sense  of  the  ex- 
aminer's finger  will  be  blunted.  In  this  event  a  recto-abdominal 
examination  will  prove  to  be  more  satisfactory. 

Differential  Diagnosis  of  Prolapse. — An  inverted  uterus  may  be 
mistaken  for  a  prolapse.  The  absence  of  a  distinct  ring  having  a 
sharp  edge  completely  surrounding  the  prolapsed  mass,  and  the 
fact  that  at  no  point  can  a  sound  be  passed  into  the  tumor,,  serve 
to  distinguish  the  two.  If  the  abdominal  walls  happen  to  be  ex- 
tremely thin  a  cup-shaped  depression  in  the  abdominal  aspect  of 
an  inverted  uterus  mav  be  made  out  bv  bimanual  touch. 


LATEROPOSITION  229 

True  hypertrophic  elongation  of  the  lower  uterine  segment  (Fig.  88a) 
has  been  spoken  of  as  a  part  of  prolapse.  It  is  diagnosed  by  dis- 
tinguishing unusual  length  of  the  lower  part  of  the  uterus  by  bi- 
manual  touch,  by  finding  a  fundus  placed  relatively  high  in  the 
pelvis,  and  increased  length  of  the  cervical  canal,  as  disclosed  by 
measuring  the  sound  passed  only  to  the  internal  os, — the  point 
where  the  tip  meets  an  obstruction.  When  the  patient  is  placed 
in  the  knee-chest  position  the  cervix  is  not  obliterated,  as  under 
normal  conditions.  True  hypertrophic  elongation  occurs  only  in 
sterile  women;  false  hypertrophic  elongation,  occurring  in  the  parous, 
is  described  in  the  chapter  on  laceration  of  the  cervix,  page  209. 

A  pedunculated  fibroid  or  polypus  is  sometimes  mistaken  for  a 
prolapse.  In  this  case  a  sound  can  be  swept  about  in  the  uterine 
cavity  at  any  point  in  the  circumference  of  the  collar  of  the  cervix 
except  at  the  side  where  the  polypus  is  attached  to  the  uterine  wall. 
There  is  no  cavity  in  the  polypus,  and  recto-abdominal  touch  re- 
veals the  presence  of  the  fundus  uteri  in  its  normal  position. 

3.  ANTEROPOSITTON 

Anteroposition  of  the  uterus,  or  a  uterus  placed  as  a  whole  too 
near  the  symphysis  pubis,  is  due  to  retro-uterine  tumors,  such  as  a 
pelvic  hematocelc,  dermoid  ovarian  tumor,  or  tumor  of  the  rectum, 
or  even  an  overloaded  rectum.  As  far  as  we  know,  this  position 
of  the  uterus  is  of  no  significance  from  a  pathological  or  clinical 
point  of  view.  The  diagnosis  is  established  by  the  bimanual 
touch;  noting  that  the  uterus  is  not  in  its  normal  situation  but 
close  against  the  pubic  arch. 

4.  LATEROPOSITION 

The  uterus  may  be  displaced  to  the  right  side  or  to  the  left  side 
by  a  tumor  or  an  inflammatory  mass,  the  uterus  being  pushed  to 
the  opposite  side  of  the  pelvis  to  that  occupied  by  the  tumor  mass. 
Cicatricial  contraction  following  an  effusion  in  one  broad  ligament 
may  draw  the  uterus  to  that  side  of  the  pelvis.  Such  a  malposi- 
tion is  to  be  noted  for  the  purpose  of  removing  its  cause  and 
has  significance  only  because  of  the  pathological  condition  pro- 
ducing it. 


212  DISEASES  OF  THE  UTERINE  LIGAMENTS 

Varicocele  of  the  Broad  Ligament. — This  is  not  a  very  rare  disease. 
It  consists  of  dilated  veins  running  transversely  in  the  upper  part 
of  the  broad  ligament  and  forming  a  tumor  that  may  be  as  large  as 
a  small  lien's  egg,  though  generally  much  smaller.  Yaricocele  is 
found  more  often  on  the  left  side.  Perhaps  this  is  because  the  left 
ovarian  vein  is  valveless  and  opens  into  the  renal  vein  at  a  right 
angle.  It  is  possible  to  make  a  diagnosis  by  recto-abdominal  palpa- 
tion by  rinding  a  doughy-feeling  tumor  in  the  broad  ligament,  but  as 
such  a  tumor  is  not  tense  except  when  the  patient  is  in  the  erect 
posture1,  the  diagnostician  would  be  likely  to  miss  it  during  the 
usual  examination  made  with  the  patient  in  the  dorsal  position. 
If  there  are  varicosities  elsewhere  in  the  body  varicocele  of  the 
broad  ligament  should  come  into  the  physician's  mind  and  he 
should  examine  the  patient  in  the  standing  position.  The  char- 
acteristic symptom  of  varicocele  of  the  broad  ligament  is  a  dull 
aching  pain  in  the  pelvis  or  back. 

THE  ROUND  LIGAMENTS 

The  round  ligaments  vary  much  in  size  and  in  length  in  different 
individuals,  therefore  their  ability  to  steady  the  uterus  as  guys  is  a 
variable  quantity.  The  muscular  fibers  are  situated  in  the  inner 
two-thirds  of  the  ligament  and  sometimes  the  ligaments  are  nothing 
but  the  slenderest  of  cords.  Fibroma,  fibromyoma,  adenomyoma, 
fibromyxoma,  and  sarcoma  of  the  round  ligament  have  been  de- 
scribed. The  tumor  is  generally  unilateral  but  may  be  bilateral. 
These  tumors  are  thought  by  some  writers  to  be  associated  with 
fibroids  of  the  uterus.  They  may  be  found  in  any  portion  of  the 
course  of  the  ligament, — in  the  abdominal  cavity,  the  inguinal 
canal,  or  in  the  labium  majus, — and  they  develop  slowly,  but  may 
be  stimulated  to  more  rapid  growth  by  the  presence  of  pregnancy. 
The  tumors  are  hard  and  generally  pedunculated. 

Diagnosis  of  Tumors  of  the  Round  Ligament. — If  a  tumor  is  situ- 
ated within  the  peritoneal  cavity  it  is  felt  by  bimanual  palpation 
in  the  front  of  the  pelvis  on  one  side.  If  it  is  in  the  inguinal  canal 
or  labium  majus  the  tumor  is  felt  from  the  outside  in  the  course  of 
the  canal  or  in  the  labium.  It  must  be  differentiated  from  omental 
or  ovarian  hernia,  hydrocele  of  the  round  ligament,  a  cyst  of  Bar- 
tholin's  gland,  or  enlarged  inguinal  lymphatic  glands.  There  is  no 


DIAGNOSIS  OF   LACERATION 


209 


them.  The  injuries  must  be  followed  carefully  to  their  limits, 
whether  they  be  confined  to  the  cervix,  or  if  they  extend  to  the 
vagina,  or  even  to  the  rectum  or  the  bladder. 

(6)  Old  Lacerations.  —  If  every  woman  were  submitted  to  a 
careful  uterine  examination  after  child-bearing,  and  injuries  of  the 
cervix,  as  well  as  those  of  the  pelvic  floor,  found  and  repaired,  there 
would  be  comparatively  little  for  the  gynecologist  to  do.  It  hap- 
pens, however,  that  most  of  the  lacerations  of  the  cervix  come 
under  the  physician's  notice  for  the 
first  time  some  years  after  their  re- 
ceipt. At  this  time  the  diagnosis  is 
difficult  because  of  enlargement  and 
distortion  of  the  cervix,  eversion  of 
the  lips,  and  cystic  degeneration  of 
the  Nabothian  follicles  and  erosion. 
The  trained  vaginal  touch  after  a  little 
practice  detects  all  of  these  features 
even  to  the  erosion.  For  inspection 
the  Sims  position  is  best.  Search  first 
for  the  arbor  vitaB  and  thus  deter- 
mine the  situation  of  the  cervical 
canal.  The  passage  of  the  sound 
helps  to  define  the  situation  of  "this 
canal,  but  the  physician  must  be  O11  FIG.  83.— Unilateral  Lacera- 
his  guard  not  to  be  misled  by  the  tions  of  the  Cervix,  Producing 
malpositions  of  the  uterus  found  in  Obliquity  of  the  Long  Axis  of  the 

Uterus.       (After    Emmet.)      The 

cases  of  unilateral  tear    as    pointed  Reduplication  of  the  Vagina  is 
out  by  Emmet.     (Sec  Fig.  83.)    In  shown  at  W. 
this   event  the  sound   passed   to  the 

cornu  opposite  to  the  seat  of  the  laceration  may  appear  to  be  in 
the  canal  (see  figure),  but  because  of  the  tilting  of  the  fund  us 
toward  the  laceration  the  sound  occupies  the  laceration  and  not 
the  normal  cervical  canal.  Here  a  search  for  the  arbor  vitae  will 
help  to  set  us  right  and  the  bimanual  touch  will  also  assist. 
Putting  the  patient  in  the  knee-chest  position,  thus  permitting 
the  uterus  to  fall  toward  the  abdomen  high  in  the  pelvis,  straightens 
its  axis  and  also  pulls  out  the  reduplication  of  the  vagina  on  the 
side  where  the  laceration  is  situated.  In  all  lacerations  of  severe 
grade  it  is  well  to  study  the  conditions  as  seen  through  the  specu- 
14 


232  MALPOSITIONS  OF  THE  UTERUS 

with  the  addition,  in  the  case  of  retroposition  with  anteflexion,  of 
adhesions  limiting  the  mobility  of  the  uterus. 

Anteflexion  may  be  acquired,  however,  as  in  the  case  of  a  uterus 
with  softened  tissues  having  a  fibroid  in  the  anterior  wall  of  the 
fundus.  Excessive  straining  at  stool  tends  to  bend  the  cervix 
forward  and  at  the  same  time  to  fold  the  fundus  and  body  of  the 
uterus  forward  and  downward,  provided  the  forward  excursion 
of  the  region  of  the  internal  os  is  limited.  Thus  a  flexed  uterus 
becomes  more  flexed.  The  uterine  canal  is  obstructed  mechan- 
ically at  the  internal  os  by  excessive  flexure,  therefore  we  should 
expect  these  patients  to  suffer  with  blood  stasis  and  endometritis, 
the  results  of  a  damming  up  and  decomposition  of  the  uterine  dis- 
charges, and  this  is  usually  the  case. 

Vesical  symptoms  are  due  to  the  backward  traction  of  the  cervix 
on  the  vesical  neck  and  to  the  interference  offered  by  the  forward 
flexed  fundus  uteri  to  the  filling  of  the  bladder.  Of  the  two  the 
former  is  the  more  important  cause. 

I  have  previously  called  attention  to  the  frequency  of  retro- 
position  with  anteflexion  (''Division  of  the  Utero-Sacral  Liga- 
ments and  Suspensio  Uteri  for  Immobile  Retroposition  with  Ante- 
flexion,"  Amer.  Gyn.  and  Obstet.  Jour.,  Jan.,  1898,  and  "Further 
Experience  with  the  Operative  Treatment  of  Anteflexion,"  Amer. 
Gyn.  and  Obstet.  Jour.,  Jan.,  1900).  The  condition  has  not  been 
recognized  generally  by  the  profession,  having  been  classed  broadly 
as  ret  reversion. 

Diagnosis  of  Retroposition  with  Anteflexion. — The  diagnosis  is 
made  by  finding  the  uterus  as  a  whole  in  the  extreme  back  part  of 
the  pelvis.  This  is  done  by  practising  the  bimanual  vagino- 
abdominal  or  recto-abdominal  touch.  The  cervix  is  in  the  axis 
of  the  vagina,  the  anterior  lip  is  flattened  and  short,  the  crown  of 
the  cervix  being  in  extreme  cases  practically  continuous  with  the 
front  wall  of  the  vagina.  The  cervix,  in  the  axis  of  the  vagina,  is 
not  so  long,  as  a  rule,  as  in  the  case  of  the  puerile  cervix,  but  it  is 
long  as  compared  with  the  fundus,  representing  two-thirds  of  the 
entire  length  of  the  uterus.  Its  tissues  are  generally  indurated 
and  more  or  less  tender:  there  is  a  cervical  discharge  from  a  pin- 
hole  os.  The  fundus  is  flexed  forward  and  may  be  grasped  be- 
tween the  forefinger  in  the  vagina  and  the  fingers  of  the  hand  on 
the  abdomen.  It  mar  be  enlarged  or  it  mav  not,  and  tenderness 


HERNIA  OF  THE  UTERUS  233 

on  pressure  and  induration  are  not  necessarily  present.  Shortened 
utero-sacral  ligaments  or  extraligamentous  adhesions — these  latter 
rarely  present — limit  the  forward  excursion  of  the  uterus  as  de- 
termined by  making  forward  traction  with  the  examining  hands. 
Rigidity  of  the  tissues  at  the  angle  of  flexion  is  determined  by 
manipulating  the  uterus.  Downward  pressure  on  the  fundus  by 
the  hand  on  the  abdomen  moves  the  cervix  backward,  and  up- 
ward pressure  on  the  fundus  by  the  finger  in  the  vagina  moves 
the  cervix  forward.  It  is  impossible  to  change  the  relation  of 
cervix  and  fundus  to  each  other  by  separating  two  fingers  placed 
between  them  in  the  vagina. 

As  a  rule  it  is  not  necessary  to  pass  the  sound  in  order  to  verify 
the  diagnosis.  In  fat  women,  however,  with  thick  and  rigid 
abdominal  walls,  this  procedure  may  be  necessary.  Select  a  flex- 
ible sound  of  small  caliber.  This  is  better  and  safer  than  a  probe, 
the  tip  of  which  will  catch  in  pockets  of  the  lining  mucous  mem- 
brane. Bend  the  sound  so  that  it  corresponds  to  the  bent  uterine 
canal  as  determined  by  palpation;  fix  the  cervix  with  a  tenaculum 
and  make  gentle  traction,  thus  straightening  the  uterine  canal  as 
much  as  possible.  Pass  the  sound  tentatively,  withdraw  and 
rebend,  until  the  tip  will  slip  through  the  internal  os.  Note  the 
point  of  sensitiveness  in  the  uterine  canal,  if  any,  the  distance  of 
the  internal  os  from  the  external  os,  and  the  total  depth  of  the 
uterine  cavity.  Note  thus  the  relation  that  the  length  of  the 
cervical  canal  bears  to  the  length  of  the  uterine  cavity  proper; 
also  consider  the  tightness  of  the  internal  os,  the  capacity  of  the 
uterine  cavity,  and  the  amount  and  character  of  the  discharge. 
If  blood  follows  the  gentle  passing  of  the  sound  and  tenderness  is 
present,  one  may  diagnose  endometritis. 

0.  HERXIA  OF  THE  UTERUS 

Hernia  of  the  uterus  through  the  inguinal  or  the  crural  canal  is 
a  rare  anomaly.  The  diagnosis  is  established  by  determining  the 
absence  of  the  uterus  from  its  normal  situation  and  its  presence  in 
the  hernial  sac.  The  latter  is  a  most  difficult  matter  and  most  of 
these  cases  have  been  operated  on  for  strangulated  hernia,  when 
the  diagnosis  was  made.  Congestion  or  tumefaction  of  the  hernial 
tumor  containing  a  uterus  should  be  looked  for  at  the  time  of 


224 


MALPOSITIONS  OF  THE  UTERUS 


chronic,  distention  of  the  urinary  bladder,  chronic  fulness  of  the 
rectum,  sudden  jar,  etc.  (see  Retroversion,  page  234).  When 
once  the  axis  has  been  changed,  the  intra-abdominal  pressure  is  ex- 
erted against  the  anterior  face  of  the  uterus  and  the  broad  liga- 
ments, and  increased  pressure  accentuates  the  retroversion,  and  at 
the  same  time  pushes  down  the  uterus,  now  in  the  same  axis  as 
the  vagina.  Factors  which  make  for  greater  downward  pressure, 
such  as  a  persistent  cough  or  violent  straining  because  of  chronic 


FIG.  88.  —  Prolapse  of  the  Vagina  and  Cervix,  with  Elongation  of  the  Supra- 
vaginal  Cervix. 

diarrhea,  tend  to  cause  descensus  uteri.  Constant  straining  is  an 
important  factor  in  the  causation  of  prolapse;  therefore  prolapse 
is  found  most  frequently  among  women  of  the  working  classes. 
These  women  are  apt  to  get  up  and  begin  work  soon  after  con- 
finement when  the  uterus  is  large  and  heavy  and  relroverted. 

Inversion  of  the  vagina  may  lake  place  without  actual  descent 
of  the  uterus  because  of  the  elasticity  of  the  vagina,  and,  prolapse 
mav  be  simulated  bv  elongation  of  the  lower  uterine  segment. 


DESCENT  OR  PROLAPSE 


221 


the  uterus,  therefore  the  round  ligaments  can  not  support  the 
uterus  except  in  cases  of  extreme  prolapse.  On  the  other  hand, 
the  attachments  of  the  utero-sacral  ligaments  to  the  pelvic  wall 
near  the  second  piece  of  the  sacrum  are  a  trifle  higher  than  their 
insertions  into  the  uterus  at  the  level  of  the  internal  os.  They 
are  normally  firm  and  strong  and  act  as  true  supports. 
The  broad  ligaments  check  lateral  motion  and  limit  the  uterine 


ThrieTal 

ofj  slanting  sbflf-  -  - 

Crest  of  iliuiT].  _  J[j£ 


FIG.  86. — Right  Side  of  Abdominal  Wall  Has  Been  Removed,  Showing  Fun- 
nel Shape  of  Abdominal  Cavity,  which  Is  Wide  Above  and  Narrow  Below,  also  the 
Slanting  Shelf  which  Gives  Partial  Support  to  the  Viscera.  (After  Corning.) 

movements  largely  to  forward  and  backward  excursions.  The 
intra-abdominal  pressure  is  exerted  on  the  posterior  aspect  of  their 
broad  surfaces  and  thereby  they  assist  either  in  retaining  the 
uterus  in  anteversion,  or,  if  the  axis  of  the  uterus  has  been  changed 
from  anteversion  to  retroversion,  the  pressure  being  on  their 
posterior  aspects,  they  assist  in  keeping  the  womb  in  that  position 
and  in  aiding  prolapse.  The  thick  bases  of  the  broad  ligaments 


236  MALPOSITIONS  OF  THE  UTERUS 

ried  women.  Possibly  habitual  constipation  and  overdistention 
of  the  bladder  and  faulty  posture  may  have  something  to  do 
with  it.  The  symptoms  of  retroversio-flexion  are  not  distinctive 
and  there  may  be  no  symptoms.  If  present,  they  are:  a  sense  of 
weight  in  the  pelvis  or  bearing-down  feeling,  irregularities  of  men- 
struation, uterine  catarrh,  constipation,  frequency  of  micturition, 
and  abortion  and  sterility.  In  the  case  of  retro  flexion,  if  preg- 
nancy occurs  in  the  retroflexed  fundus  there  is  less  likelihood  of 
spontaneous  reposition  than  in  retro  version,  and  therefore  abortion 
is  more  likely  to  occur.  The  bladder  and  rectal  symptoms  are 
apt  to  be  more  pronounced  in  retroflexion  than  in  retroversion 
because  in  the  former  there  is  more  dragging  on  the  neck  of  the 
bladder  and  a  sensitive  fundus  impinges  more  directly  upon  the 
lower  rectum.  The  degree  of  retroversion  is  a  variable  quantity. 
Formerly  it  was  customary  to  define  the  amount  of  tipping  of  the 
uterine  axis  with  great  exactness  and  the  retroversion  was  said  to 
be  in  the  first,  second,  or  third  degree,  according  as  it  was  tipped 
backward  so  that  its  long  axis  pointed,  respectively,  at  the  promon- 
tory of  the  sacrum,  in  the  axis  of  the  vagina,  or  it  exceeded  the 
last  amount  of  tilting.  Now  we  consider  the  old  first  degree  to 
be  within  normal  limits.  It  is  well,  however,  to  preserve  these  dis- 
tinctions for  purposes  of  description. 

Diagnosis  of  Retroversio-flexion. — The  bimanual  touch  shows  the 
fundus  to  be  absent  from  its  normal  situation  and  the  cervix  in  the 
axis  of  the  vagina.  If  the  abdominal  walls  are  thin  and  relaxed 
it  is  possible  often  to  palpate  the  fundus  bimanually,  even  though 
it  is  retroflexed.  In  less  favorable  cases  the  hand  on  the  abdomen 
determines  the  absence  of  the  fundus  in  its  normal  position.  The 
finger  in  the  vagina  notes  a  sense  of  resistance  in  the  cul-de-sac, 
or  in  the  case  of  retroflexion,  a  rounded  body  in  that  situation. 
Rectal  touch  is  of  great  assistance  in  the  diagnosis  of  both  retro- 
version  and  retroflexion,  for  by  the  rectum  the  examiner's  finger 
can  reach  a  higher  point  in  the  pelvis  than  by  the  vagina.  One  of 
the  most  important  facts  to  determine  is  the  mobility  of  the  uterus; 
therefore  attempt  to  dislodge  it.  To  do  this,  make  an  upward  pres- 
sure on  the  fundus  by  the  left  forefinger — protected  by  a  cot — in 
the  rectum  while  the  cervix  is  pushed  backward  by  the  right  fore- 
finger in  the  vagina,  the  patient  being  in  Sims  position.  If  this 
is  unsuccessful,  hook  a  tenaculum  into  the  cervix  and  make  down- 


RETRO  VERSION  237 

ward  traction  while  the  rectal  finger  pushes  the  fundus  up.  If 
the  fundus  has  been  displaced  from  the  hollow  of  the  sacrum  by 
these  manipulations  the  tenaculum  is  removed  from  the  cervix,  the 
left  forefinger — the  cot  having  been  removed — is  transferred  to 
the  vagina,  the  right  hand  is  passed  between  the  patient's  thighs 
to  the  abdomen  and  the  uterus  rocked  into  place  by  the  bimanual 
touch.  The  knee-chest  position  and  traction  on  the  cervix  with 
a  tenaculum  will  often  accomplish  the  reposition  of  an  obstinate 
retro  version  or  an  incarcerated  pregnant  fundus.  Sometimes  the 
displaced  fundus  is  held  between  the  utero-sacral  ligaments.  When 
the  uterus  is  raised  in  the  pelvis  these  ligaments  are  relaxed  and 
the  fundus  may  be  pushed  up  through  them.  In  some  cases,  es- 
pecially in  virgins  with  tense,  well-developed  abdominal  walls,  noth- 
ing short  of  an  anesthetic  will  permit  reposition  of  a  retroflexed 
uterus  even  though  free  from  adhesions.  During  the  manipu- 
lation the  physician  gains  a  knowledge,  through  his  sense  of  touch, 
of  the  other  pelvic  organs.  He  detects  salpingitis  or  thickenings 
denoting  adhesions.  He  notes  points  of  tenderness,  and  these  warn 
him  against  vigorous  attempts  at  reposition.  When  the  Peaslee 
rigid  uterine  sound  was  first  invented  it  was  customary  for  the 
practitioner  of  that  day  to  pass  it  into  the  uterine  cavity  and 
forcibly  pry  the  uterus  into  place,  and  the  trauma,  together  with 
the  lack  of  asepsis  which  prevailed  at  that  time,  produced  most 
disastrous  results  in  the  form  of  acute  pelvic  inflammation,  salpin- 
gitis, or  even  pelvic  abscess. 

Suppose  the  fundus  has  been  freed  from  its  abnormal  position, 
the  next  procedure  is  to  hold  the  cervix  backward  while  you  reach 
for  the  fundus  with  the  fingers  of  the  right  hand  on  the  abdomen, 
working  them  behind  it  by  gradual  and  repeated  pressure  as  the 
patient  takes  deep  inspirations.  Backward  pressure  on  the  cervix 
and  forward  rocking  on  the  fundus  restore  the  uterus  to  its  normal 
position.  The  bimanual  touch  practiced  in  the  Sims  position  is 
most  useful  for  this  procedure.  Always  be  sure  that  the  bladder 
is  empty  before  beginning  the  manipulations.  If  the  uterus  comes 
up  do  the  ovaries  also  assume  a  normal  position?  Note  their  size 
as  well  as  their  mobility.  In  exceptional  cases  the  aseptic  sound 
may  be  passed  to  confirm  a  diagnosis,  especially  in  cases  of  retro- 
flexion,  lien-  it  is  generally  necessary  to  pass  a  sound  to  differ- 
entiate from  a  fibroid  in  the  posterior  uterine  wall.  It  is  necessary 


220  MALPOSITIONS  OF  THE  UTERUS 

lion  and  running  almost  transversely  from  the  cervix  to  the  hymen, 
now  becomes  a  straight  or  open  tube,  leading  almost  directly  down- 
ward from  the  cervix  to  the  introitus. 

The  pelvic  door,  according  to  Hart  and  Barbour,  may  be  divided 
up  into  an  anterior  and  a  posterior  segment.  The  anterior  seg- 
ment is  a  relatively  movable  one,  the  posterior  is  relatively  fixed. 
The  anterior  or  pubic  segment  consists  of  anterior  vaginal  wall, 
urethra,  and  bladder,  all  attached  loosely  to  the  symphysis  pubis 
by  retropubic  deposits  of  fat.  The  posterior  or  sacral  segment 
is  made  up  of  posterior  vaginal  wall,  the  muscles  and  fascia?  of 
the  perineum,  and  the  rectum,  all  firmly  bound  to  the  sacrum  and 
coccyx.  During  labor  the  anterior  segment  is  drawn  up;  the 
posterior  segment  is  driven  down.  In  the  formation  of  prolapse 
the  anterior  segment,  because  of  the  injury  of  the  posterior  seg- 
ment, swings  downward  and  backward — the  retropubic  fat  giving 
way  with  consequent  dislocation  of  bladder  and  urethra.  It  is 
plain  that  a  tipping  back  of  the  uterus  on  its  axis,  so  that  it  may 
get  into  the  same  axis  as  the  vagina,  is  a  requisite  to  the  descent 
of  that  organ,  and  that  this  tipping  backward  is  made  possible  by 
injury  of  the  posterior  segment  of  the  pelvic  floor  and  dislocation 
of  the  anterior  segment,  so  that  the  cervix — not  stayed  from  be- 
hind and  having  no  firm  tissue  in  front  of  it— swings  forward  until 
its  long  axis  coincides  with  the  long  axis  of  the  vagina.  This 
subject  will  be  made  clearer  when  we  consider  the  different  direc- 
tions in  which  under  varying  conditions  the  uitra-abdominal 
pressure  is  applied  to  the  fundus  uteri. 

(b)  The  uterine  ligaments  and  the  attachments  of  the  uterus  to 
the  surrounding  structures. 

The  ligaments,  described  in  Chapter  V,  page  44,  consist  of 
three  pairs  of  ligaments  proper — the  broad,  the  round,  and  the 
utero-sacral ;  and  the  attachments  are — the  utero-vesical  connec- 
tive tissue,  the  vagina,  and  the  retro-uterine  cellular  tissue.  In 
considering  the  causation  of  prolapse  we  must  think  of  the  woman 
being  in  the  erect  position,  because  it  is  in  this  attitude  that  the 
great  strain  is  brought  to  bear  that  causes  sacro-pubic  hernia. 
By  reference  to  the  diagram  (Fig.  84)  on  page  210  it  will  be  seen 
that  the  origins  and  insertions  of  all  the  ligaments  lie  in  nearly 
the  same  plane.  As  a  matter  of  fact,  the  pubic  ends  of  the  round 
ligaments  are  a  little  lower  than  their  insertions  into  the  horns  of 


GENERAL  CONSIDERATIONS 


217 


ences  in  the  way  of  pressure  from  tumors  or  pelvic  inflammatory 
masses,  or  stretching  due  to  malposition  of  the  uterus. 

We  know  how  much  a  prolapsed  uterus  is  reduced  in  size  after 
it  has  been  replaced  in  a  normal  position  in  the  pelvis  and  main- 
tained there  for  a  few  hours  even.  We  know  that  a  normal  uterus, 
displaced  downward  mechanically,  becomes  congested.  It  is  fair 
to  assume  that  this  is  due  to  a  straightening  of  the  tortuous  valve- 


FIG.    84a. — Longitudinal  Median  Section  of   a  Pelvis  with  Overdistended  blad- 
der.    (Zuckerkandl.)      Note  Retroversion  of  Uterus. 

loss  veins,  thus  lessening  the  resistance  of  their  walls  to  an  in- 
creased pressure  delivered  by  the  less  convoluted  arteries. 

It  is  the  view  of  the  author  that  uterine  malpositions  have  a 
direct  mechanical  effect  on  the  pelvic  circulation,  therefore  dis- 
placements of  the  uterus  as  a  whole  are  of  more  importance  than 
changes  in  the  axis  (version),  or  changes  in  form  (flexions,  torsions, 
or  tumors). 


240  MALPOSITIONS  OF  THE  UTERUS 

3.    AXTK FLEXION 

Antcflexion  has  been  described  at  length  under  Retroposition 
with  Antcflexion.  It  is  to  be  understood  that  this  malformation 
of  the  uterus  does  occur  without  the  posterior  malposition.  What 
has  been  said  of  the  combined  disorder  applies  equally  to  the 
flexion  alone. 

4.  INVERSION 

Inversion  of  the  uterus  is  a  partial  or  complete  turning  of  the 
organ  inside  out.  It  is  of  three  sorts:  (1)  acute  puerperal  inver- 
sion, (2)  chronic  puerperal  inversion,  and  (3)  inversion  caused  by 
uterine  tumors.  The  first  sort  concerns  the  obstetrician.  The 
second  is  the  more  usual  of  the  remaining  two  forms  that  are  seen 
by  the  gynecologist. 

Puerperal  inversion  is  due  to  relaxation  of  the  uterine  muscles 
at  the  time  of  the  delivery  of  the  placenta.  Coughing  or  sneezing 
may  invert  a  relaxed  uterus;  too  much  traction  on  the  cord  and 
an  adherent  placenta  are  the  direct  causes  in  some  cases.  The 
uninverted  part  of  the  uterine  wall  may  seize  the  inverted  part 
so  that  the  uterus  looks  like  the  bottom  of  a  wine  bottle,  and  the 
contraction  of  the  unrelaxed  portion  may  continue  to  push  the 
fundus  downward  until  the  uterus  is  completely  inverted.  The 
process  may  start  in  the  lower  uterine  segment,  which  is  inverted 
first,  and  is  followed  by  the  fundus.  The  tubes  follow  necessarily 
into  the  cup  of  the  inverted  fundus  and  sometimes  also  loops  of 
intestines,  but  these  structures  are  seldom  adherent.  The  everted 
mucosa  of  the  uterine  cavity  is  dark  red  and  bleeds  easily,  and  in 
cases  of  long  standing  inversion  it  shows  regions  of  ecchymosis 
and  ulceration.  Cases  have  been  reported  where  there  were  ad- 
hesions between  the  partially  inverted  fundus  and  the  cervix. 
If  inversion  is  due  to  downward  traction  on  the  uterine  wall  by  a 
submucous  fibroid  there  is  apt  to  be  present  a  foul  uterine  dis- 
charge, for  the  fibroid  is  generally  in  a  state  of  necrosis.  The 
usual  symptoms  of  chronic  inversion  are:  pelvic  pain,  hemorrhage, 
leucorrhea,  frequency  of  micturition  and  dysuria,  and  difficulty  in 
walking  and  standing. 

Diagnosis  of  Inversion. — In  favorable  cases  where1  the  abdominal 
walls  are  relaxed  and  the  patient  is  not  fat,  the  bimanual  touch  will 


FIG.  94. — Partial  Inver- 
sion of  the  Left  Horn  of 
the  Uterus. 


FIG.  96.— Partial  Inver- 
sion Complicated  by  and 
Caused  by  a  Submucous 
Fibroid. 


FIG.  100— Complete  In- 
version Complicated  by 
a  Subperitoneal  Fibroid 
which  Resembles  the 
Uterus. ' 


FIG.  95 — Pedunculated 
Submucous  Fibroid  Sim- 
ulating Partial  Inversion. 


FIG.  97. — Partial   Inver- 
sion. 


' 


FIG.    98. — Complete    In- 


FIG.   101. — Submucous 

Fibroid  Filling  the  Vagina 

with    Normally   Situated 

Uterus  Above  Simulating       -^       nr.      T.    ,          ,   ,    i 

Condition  in  last  Figure  QFIG.  99.-Pedunculated 
Submucous  Fibroid  Pro- 
jecting from  the  External 
Os,  Resembling  an  In- 
verted Uterus. 


EIGHT   DIAGRAMS  SHOWING  INVERSION  OF  THE  UTERUS  AND  CONDITIONS 
16  SIMULATING  IT.     (DUDLEY)  FIGS.  94-101. 


242  MALPOSITIONS  OF  THE  UTERUS 

shmv  the  absence  of  the  uterus  in  its  customary  situation.  Rectal 
touch  is  of  great  use,  also  the  recto-abdominal  touch,  and  the 
rectal  touch  with  a  sound  in  the  bladder.  In  extremely  favorable 
cases  the  depression  of  the  inverted  cup  may  be  made  out  by  the 
abdominal  hand.  By  vagina  the  partial  or  completely  inverted 
uterus  is  felt  and  seen,  and  occasionally  the  orifices  of  the  Fallopian 
tubes  can  be  demonstrated  in  the  inverted  fundus.  The  ring  of 
the  cervix  can  be  felt  by  the  finger  swept  about  the  inverted  fundus. 
The  difficult  point  in  diagnosis  is  to  differentiate  complete  inver- 
sion from  submucous  myoma. 

By  reference  to  the  figures  on  page  241,  it  will  be  seen  that  a 
myoma  may  spring  from  the  fundus,  body,  or  cervix.  It  may  be 
sessile,  or  have  a  short  pedicle  or  a  long  one.  Fig.  100  shows 
an  unusual  condition:  a  pedunculated  subperitoneal  fibroid  at- 
tached to  the  cervical  region — the  uterus  being  in  a  state  of  com- 
plete inversion — and  the  fibroid  tumor  presents  to  the  examiner's 
touch  the  size  and  shape  of  a  uterus  in  a  normal  situation.  In 
such  a  case  it  would  be  extremely  difficult  to  tell  the  uterus  from 
the  tumor.  Detection  of  the  orifices  of  the  Fallopian  tubes  and 
also  the  ring  of  the  cervix  would  be  the  distinguishing  features. 
Complete  prolapse  can  be  differentiated  from  an  inversion  by 
finding  in  the  prolapse  the  external  os  uteri;  the  extruded  mass 
is  wider  above  and  narrower  below;  and  the  vagina  is  everted  to  a 
greater  or  less  degree,  as  shown  by  the  fact  that  the  point  of  a 
sound  introduced  into  the  bladder  can  be  felt  in  the  hernia.  In 
the  case  of  inversion,  on  the  other  hand,  there  is  no  external  os, 
the  orifices  of  the  tubes  may  be  seen,  and  a  sound  in  the  bladder 
goes  upward,  except  very  rarely  when  the  vagina  also  is  inverted. 

Differential  Diagnosis  of  Inversion. — The  following  is  a  tabulated 
statement  of  the  differential  diagnosis  between  complete  inversion 
and  pedunculated  fibroid  in  the  vagina,  and  incomplete  inversion 
and  intra-utenne  submucous  fibroid. 


Complete  Inversi-on.  Pedunculated  Fibroid  in  Vagina. 

1.  Sweeping  finger  and  sound  about  1.  Tumor  is  attached  at  one  point  by 
tumor  shows  it  to  have  no  point  of  at-  a    broader    or    narrower    attachment, 
tachment.  Verify  location  and  size  of  attachment 

by  the  sound. 

2.  Sound  will  enter  ring  of  cervix  but  2.  Sound  goes  to  fundus  a  distance 
a  short  distance.  of  21  inches  (six  centimeters'),  at  least. 


TORSION  243 

Complete  Inversion.  Pedunculated  Fibroid  in  Vagina. 

(continued)  (continued) 

3.  Uterus  absent  in  abdomen  to  bi-          3.  Uterus  present  in  abdomen, 
manual  examination. 

4.  Hernia  mass  is  symmetrical,  lar-          4.  Mass  may  be  asymmetrical. 
ger  below  and  narrower  above. 

5.  Orifices  of  the  Fallopian  tubes  are          5-  No  orifices  of  the  Fallopian  tubes, 
often  demonstrable. 

Incomplete  Inversion.  Intra-Uterine  Submucous  Fibroid. 

1.  Uterine  cavity  is  shallow  as  meas-  1.  Cavity  deep, 
ured  by  sound. 

2.  Cup-shaped  depression  in  uterus  2.  No  cup-shaped  depression, 
felt  bimanually. 

3.  Symptoms  date  from  parturition.  3.  Symptoms  do  not  date  from  par- 

turition. 

5.  TORSION  OF  THE  UTERUS 

Torsion,  or  twisting  of  the  uterus  on  its  own  long  axis,  may  be 
complete  or  it  may  be  partial.  In  the  former  the  entire  uterus  is 
twisted  to  one  side  or  the  other,  generally  not  more  than  half  a 
turn,  as  in  the  cases  of  anteflexion  or  retroflexion  where  one 
utero-sacral  ligament  is  shortened.  In  the  case  of  tumors  growing 
from  one  side  of  the  pelvis,  howTevcr,  the  uterus  may  be  twisted 
several  times  on  its  own  axis.  Torsion  of  the  uterus  occurring  with 
a  fibroid  of  subserous  evolution,  or  an  ovarian  tumor  having  a 
short  pedicle,  is  generally  partial.  The  cervix  uteri,  being  steadied 
by  the  insertions  of  the  broad  ligaments,  is  not  so  apt  to  partici- 
pate in  the  twist  and  the  uterus  is  twisted  on  itself,  the  fundus 
anil  body  alone  taking  part  in  the  twist. 

Torsion  is  especially  apt  to  be  found  in  the  case  of  double  uterus 
or  uterus  bicornis. 

The  diagnosis  is  made1  by  determining  by  the  bimanual  touch 
the  position  of  the  ovaries  and  also  the  situation  and  direction  of 
the  transverse  axis  of  the  fundus  with  reference  to  the  cervix.  In 
the  event  of  complete  torsion  of  the  uterus  the  transverse  axis  of 
the  external  os  may  be  seen  through  the  vaginal  speculum  to  be 
turned  away  from  the  normal. 


CHAPTER  XV 

THE    DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

Definition,  p.  244.  Pathology,  p.  244.  Classification,  p.  245.  Situation, 
p.  248.  Frequency,  p.  248.  Etiology,  p.  250.  Course  and  Develop- 
ment, p.  251.  Degenerations,  p.  252.  Complications,  p.  255.  Effect  on 
neighboring  organs,  p.  257.  Effect  on  distant  organs,  and  on  the  system, 
p.  258.  Relation  of  fibroid  tumors  to  heart  disease,  p.  259.  Dangerous 
to  life,  p.  2(50.  Symptoms,  p.  260.  Symptoms  of  adenomyoma,  p.  262. 
Diagnosis  and  differential  diagnosis,  p.  262.  Subserous  fibroids,  p.  262. 
Intraligamentous  fibroids,  p.  263.  Interstitial  fibroids,  p.  263.  Submucous 
fibroids,  p.  264. 

DEFINITION 

FIBROID  tumor,  also  called  myoma,  fibromyoma  or  fibroma  of  the 
uterus,  is  a  nodular  growth  developing  from  some  portion  of  the 
uterus,  usually,  but  not  always,  above  the  cervix,  varying  in  size 
from  a  minute  speck  to  a  mass  or  masses  filling  the  pelvic  and 
abdominal  cavities. 

PATHOLOGY 

The  largest  fibroid  which  I  have  found  recorded  was  one  re- 
moved at  autopsy  from  a  single  woman  fifty-three  years  of  age 
by  S.  H.  Hunt  of  Long  Branch,  N.  J.  (Amer.  Jour.  Obstet., 
1888,  XXL,  p.  62.)  It  weighed  one  hundred  and  forty  pounds 
and  the  cadaver  after  the  removal  of  the  tumor  weighed  ninety- 
five  pounds. 

The  tumors  are  generally  round  in  shape,  with  smooth  surface, 
but  may  be  pear-shaped,  kidney-shaped,  mulberry-shaped;  may 
be  molds  of  the  pelvic  cavity,  or,  very  rarely,  may  resemble  a 
fetus.  They  are  single  or  multiple,  as  many  as  one  hundred  and 
fifty  tumors  having  been  found  in  the  uterus  by  Bland-Sutton. 
(Brit.  Mctl  Jour..  April  6.  1001.)  They  are  of  a  hard  consistence, 
though  a  predominance  of  muscular  tissue  in  their  structure,  or 
degenerative  changes,  may  render  them  softer.  They  are  classed 

244 


CLASSIFICATION  245 

as  benign  tumors  because  they  do  not  "eat  up"  the  surrounding 
tissues  by  extending  into  their  substance,  and  they  do  not  cause 
destruction  by  metastases.  They  are  composed  of  the  same  tissues 
as  the  uterus,  namely,  unstriped  muscle  fibers  and  connective 
tissue.  On  section  a  fibroid  tumor  is  of  a  glistening  white,  or 
whitish-yellow  color  and  is  seen  to  be  made  up  of  a  disorderly 
intertwining  of  muscular  and  connective-tissue  fibers.  In  the  larger 
masses,  however,  these  are  grouped  in  more  or  less  well-defined 
whorls  (see  Fig.  106)  which  somewhat  resemble  knots  in  a  piece 
of  wood.  Between  the  groups  of  fibers  run  arteries,  veins,  and 
lymph  channels  derived  from  the  normal  vessels  of  the  uterus, 
ramifying  at  first  beneath  the  capsule  of  the  tumor  and  then 
plunging  directly  into  its  interior.  As  a  rule  these  tumors  are 
poorly  nourished  because  they  derive  their  blood  from  the  sur- 
rounding constricted  uterine  tissue.  Occasionally  they  are  sup- 
plied by  large  vessels  through  adhesions  to  surrounding  organs. 


CLASSIFICATION 

Fibroid  tumors  may  be  classified  according  to  their  situation  with 
reference  to  the  uterus.  They  are — 

1.  Subserous, 

(a)  Intraligamentous. 
(6)  Tumors  of  the  cervix. 

2.  Interstitial. 

3.  Submucous. 

They  are  described  further  by  defining  their  number  and  size, 
and  by  noting  any  special  kind,  as  adenomyoma.  For  instance, 
in  Fig.  102  we  see  a  specimen  of  a  multiple  fibroid  uterus:  an 
interstitial  fibroid  of  the  anterior  uterine  wall,  a  subserous  fibroid 
springing  from  tho  fundus  uteri,  and  an  interstitial  tumor  of  the 
posterior  wall.  All  fibroids  originate  in  the  uterine  muscle,  there- 
fore all  are  interstitial  in  the  beginning.  If  the  tumor  develops  in 
the  outer  wall  of  the  uterus  and  grows  from  the  uterus  under  the 
peritoneum,  it  is  called  an  adenomyoma. 

Adenomyoma  is  a  special  variety  of  myoma  characterized  by  the 
presence  of  glands  similar  to  those  found  in  the  uterine  mucosa. 
Thomas  S.  Cullen  (''Adenomyoma  of  the  Uterus,"  1908)  found 


210          DIAGNOSIS   OF    FIBROID  TUMORS   OF  THE   UTERUS 

To  cases  of  adenomyoma  among  1283  cases  of  myoma  examined 
microscopically  in  the  Johns  Hopkins  Hospital  Surgical-Patho- 
logical Laboratory  (luring  thirteen  years,  or  5.7  per  cent  of  all 
fibroids.  These  tumors  are  diffuse  arid  may  or  may  not  be  definitely 
encapsulated. 

1 .  Subserous  Fibroid  Tumor. — Such  tumors  have  the  greater  part 
of  their  periphery  outside  the  uterine  wall  and  have  no  considerable 
covering  of  uterine  tissue.  (See  Fig.  102,  upper  tumor.)  The 


I" ic,.  102. — Multiple  Fibroids,  One  Subserous  and  Two  Interstitial.     (Winter.) 

greater  the  size  of  the  subserous  tumor  the  more  it  is  separated 
from  the  uterus,  as  a  rule.  It  may  be  relatively  small  or  large. 
If,  instead  of  developing  under  the  serosa,  the  tumor  separates  the 
folds  of  the  broad  ligament  and  distorts  the  viscera  to  a  greater  or 
less  degree,  it  is  called  an 

(a)  Intraligamentous  Fibroid  Tumor.  (See  Fig.  10").) — These 
tumors  have  the  greater  part  of  their  circumference  outside  the 
uterus  and  are  not  covered  by  uterine  tissue.  Noble  ("Clynecology 
and  Abdominal  Surgery."  II.  A.  Kelly  and  ('.  P.  Noble,  1007.  p.  (MM)) 


247 

found  this  form  of  tumor  in  3.5  per  cent  of  the  2,274  cases  of  fibroid 
tumor  he  studied.     The  same  characteristics  belong  to 

(6)  Tumors  which  originate  in  the  lower  posterior  segment  of  the 
uterus  and  grow  into  the  cervix  and  then  into  the  posterior  pelvis, 
or  those  rare  tumors  which  originate  in  the  cervix  itself  and  de- 
velop away  from  the  uterus.  (See  Fig.  '108.)  The  cervix,  to 
be  sure,  has  no  covering  of  peritoneum.  As  the  tumor  increases 
in  size  and  rises  in  the  pelvis  it  pushes  the  peritoneum  before  it. 
Therefore,  this  class  of  tumors  may  be  included  among  the  sub- 


FIG.    103. — Large   Multinodular   Subperitoneal   Fibroid  with  Thin  Abdominal 
Walls.     .Seen  in  Profile.     (Kelly.) 

serous.  In  subserous  fibroids  the  uterine  cavity  is  altered  little  if 
at  all  in  length  or  shape. 

'2.  Interstitial  (intramural,  intraparietal)  fibroid  tumors  are  those 
which  are  situated  in  the  wall  of  the  uterus  and  are  surrounded 
by  a  covering  of  uterine  musculature.  (See  Figs.  102  and  104.) 
They  may  or  they  may  not  alter  the  contour  of  the  uterus.  The 
uterine  cavity  is  almost  always  lengthened,  and  it  may  be  broad- 
ened and  made  asymmetrical  in  shape  by  this  form  of  tumor. 

3.  Submucous  Fibroid  Tumors. — These  are  the  tumors  which  de- 
velop into  the  uterine  cavity  and  are  covered  with  mucous  mem- 
brane and  with  little,  if  any,  of  the  uterine  musculature.  (See 
Figs.  104  and  100.)  Of  all  the  three  varieties  these  cause  the 
greatest  changes  in  the  form  of  the  uterine  cavity.  These  are 


248         DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 


the  bleeding  fibroids.  The  pressure  exerted  by  the  tumor  on 
the  nervous  mechanism  of  the  uterus  sets  up  reflex  uterine  con- 
tractions producing  a  gradual  delivery  of  the  tumor.  At  first 

the  tumor  becomes  pedunculated;  then 
the  pedicle  is  elongated  until  the  inter- 
nal os  has  been  dilated.  Finally,  in 
favorable  cases,  the  tumor  is  delivered. 
More  often  necrosis  of  the  tumor  sets 
in  before  the  delivery  is  accomplished, 
and  we  have  a  Sloughing  Fibroid. 

A  pedunculated  submucous  fibroid, 
if  of  small  size,  is  called  a  fibroid 
polyp  (see  Fig.  107),  and  is  to  be  dis- 
tinguished from  a  mucous  polyp,  one  of 
the  manifestations  of  glandular  endo- 
metritis.  In  all  forms  of  fibroids,  more 
especially  in  the  submucous  and  the  in- 
terstitial, the  mucous  membrane  of  the 
corpus  uteri  may  show  evidences  of 
glandular  and  interstitial  endometritis. 
Kelly  and  Cullen  ("Myomata  of  the 

Uterus")  state  that  the  mucous  membrane  of  the  uterine  cavity 
is  generally  normal,  but  that  cervical  endometritis  is  relatively 
frequent  when  a  sloughing  submucous  myoma  exists,  otherwise 
it  is  rare  even  if  there  be  present  evidences  of  an  old  inflamma- 
tory process  in  the  ovaries  and  tubes.  Therefore  they  point  out 
that  the  surgeon  may  open  the  uterine  cavity  with  impunity  in 
the  absence  of  vaginal  discharge  and  signs  of  tubal  disease. 


FIG.     104. — Interstitial    and 
Submucous  Fibroids. 


SITUATION 

Fibroid  tumors  always  originate  in  the  substance  of  the  uterine 
wall.  They  almost  always  develop  in  the  body  rather  than  in 
the  neck  of  the  uterus,  and  they  are  more  commonly  found  in  the 
posterior  than  in  the  anterior  or  lateral  walls. 


FREQUENCY 

Fibroid  tumors  are  the  most  prevalent  of  all  neoplasms  affecting 
the    uterus.     As    regards    their    frequency    among    women,  most 


FREQUENCY 


249 


authors  quote  Bayle  (S.  H,  Bayle,  "Diet."  en  60  vol.,  Paris,  1813,  t. 
VII.,  p.  73)  who  stated  as  long  ago  as  1813  that  20  per  cent  of  all 
women  over  thirty-five  years  of  age  have  fibroids;  but  as  other 
authors  have  arrived  at  different  results  (Klob,  for  instance,  assert- 
ing that  40  per  cent  of  the  uteri  of  women  who  die  after  the  fiftieth 
year  contain  fibroid  tumors),  and  as  Bayle's  opinion  has  not  been 
confirmed,  we  may  state  that  the  exact  frequency  of  the  tumors  is 
yet  to  be  determined.  They  are  met  with  mostly  during  the  period 
of  sexual  maturity,  between  the  ages  of  thirty  and  fifty  years,  being 
rare  before  twenty  and  after  fifty-five.  Gusserow,  out  of  919  cases  of 
fibroids,  found  only  15  under  twenty  years  of  age  and  only  17  over 


/f  tube. 


Left  ovary- 


FIG.  105. — Diagram  Showing  an  Tntraligamentous  Fibroid. 

sixty  years  of  age.  The  highest  percentage,  38.8,  was  between  the 
ages  of  thirty  and  forty,  and  the  next  highest,  36.7,  was  between 
forty  and  fifty.  Fibroids  are  undoubtedly  very  frequent  in  the 
negro  race.  The  autopsy  statistics  of  the  Johns  Hopkins  Hospital 
show,  according  to  Kelly  and  Cullen  ("Myomata  of  the  Uterus," 
1909),  that  out  of  742  autopsies  on  white  and  black  women,  over 
twenty  years  of  age,  20  per  cent  had  fibroids  in  their  uteri,  and  of 
these,  33.7  per  cent  of  the  black  women  had  uterine  myomata,  and 
10  per  cent  of  the  white  women  were  affected  in  this  way.  It  is 
not  vet  determined  whether  fibroids  are  more  common  among  the 


DIACNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 


single  than  the  married.  Bayle  and  other  authors  thought  that 
they  were,  while  Gusserow,  Dupuytren,  \\vst,  and  others,  hold  that 
they  are  not. 

ETIOLOGY 

The  causation  of  these1  tumors  is  even  now  unknown,  although 
the  problem  has  been  studied  assiduously  by  many  noted  investi- 


--.ves.  periton. 


'    TS^  >-.--  ;-•)].' 

Fio.    100. — Large    Submucous    Fibroid    showing    Distortion    of    the    Uterine 

Cavity.     (Kelly.) 

gators  during  the  last  fifty  years,  and  many  hypotheses  have  been 
advanced,  but  so  far  none  has  been  proved  correct.  An  ingenious 
theory  is  that  advanced  by  A.  Claisse  (These  de  Paris,  1900).  He 
thinks  they  are  due  to  infection  of  the  uterine  mucosa;  subacute 
inflammatory  lesions  of  the  mucosa,  especially  about  the  little 
blood-vessels  of  the  muscular  wall,  causing  proliferation  of  round 
cells,  which  are  transformed  into  fibrous  tissue.  Heredity  has  been 
supposed  to  play  a  part  in  the  causation  of  fibroids;  Hofmeier, 
\eit,  Kleinwachter,  and  others  considering  it  a  predisposing  cause. 
It  is  doubtful  whether  this  assumption  is  well  founded,  however, 
and  we  must  regard  the  occurrence  of  fibroid  tumors  in  members 


COURSE  AND  DEVELOPMENT'  251 

LfBH/i.RY  OF 

of  the  same  family — a  not  uncommon  happf^i^gf^^^if^ciklq^icefr  rr  ft  p 
rather  than  examples  of  heredity. 

Sexual  irritation,  such  as  masturbation  or  abnormal  sexual 
practices,  has  been  assigned  as  a  cause  of  myoma  by  Veit.  While 
the  chronic  congestion  which  is  due  to  undue  irritation  of  the 
genital  organs  may  assist  the  growth  of  a  fibroid,  it  is  difficult  to 
see  how  it  could  originate  one.  It  is  probable  that  many  fibroids 
are  of  congenital  origin,  perhaps  due  to  a  fetal  misplacement  of 
tissue  according  to  Cohnheim's  theory,  but,  as  already  stated, 
this  has  not  been  proved.  The  tumors  do  not  attain  any  con- 
siderable size  until  the  late  child-bearing  period-  therefore  age 
must  be  considered  a  factor  in  the  etiology. 

COURSE   AND    DEVELOPMENT 

The  development  of  a  fibroid  is  a  slow  affair,  generally  a  matter 
of  years.  II.  A.  Kelly  has  cited  a  case  which  was  under  medical 
observation  for  twenty-five  years  before  operation  and  two  years 
after.  ("Operative  Gynecology,"  1907,  Vol.  II.,  p.  347.)  A  large 
interstitial  tumor,  with  a  uterine  cavity  measuring  eight  or  nine 
inches,  became  larger  and  subpcritoneal  and  pedunculated  so  that 
at  operation  it  wras  found  attached  to  a  small  uterus  by  a  pedicle  1 
centimeter  long  and  3  centimeters  broad.  It  weighed  59  pounds. 

I  have  spoken  of  the  direction  of  the  growth  in  describing  the 
different  kinds  of  tumors.  Upon  the  course  taken  by  the  tumor 
in  its  growth  depends  often  its  subsequent  fate.  For  instance, 
if  it  grows  subserous  it  may  become  pedunculated  and  in  time 
may  be  separated  entirely  from  the  uterus,  receiving  its  nourish- 
ment through  adhesions  to  surrounding  structures.  Such  cases 
are  rare,  but  are  met  with  occasionally.  If,  on  the  other  hand,  the 
tumor  grows  toward  the  uterine  cavity,  it  is  apt  to  be  extruded 
through  the  external  os.  In  either  case  the  blood  supply  to  the 
tumor  is  interfered  with  and  there  is  a  tendency  to  necrosis  and 
degenerative  changes.  If  the  tumor  remains  in  the  substance  of 
the  uterus,  as  in  the  case  of  an  interstitial  fibroid,  its  nourishment  is 
established  on  a  surer  footing.  It  is  possible  for  all  tumors,  and 
for  small  tumors  especially,  to  remain  in  a  quiescent  state  for  an 
indefinite  period.  Uland-Sutton  ("Tumours  Innocent  and  Malig- 
nant," -Jth  Kdition,  1000.  p.  1ST)  calls  attention  to  the  latent  seedling 


252         DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

fibroid*,  in  vcgartl  to  which  he  says:  "If  a  number  of  uteri  be  ex- 
amined from  women  between  the  twenty-fifth  and  fiftieth  years  by 
the  simple  means  of  sectioning  them  with  a  knife,  in  a  large  propor- 
tion of  these  uteri  a  number  of  small  rounded  fibroids,  resembling 
knots  in  wood,  will  appear,  their  whiteness  being  in  strong  contrast 
with  the  redness  of  the  surrounding  muscle  tissue.  These  discrete 
bodies,  in  many  instances  no  larger  than  mustard  seeds,  are  in 
histologic  structure  identical  with  the  fully  grown  tumours." 


FIG.  107. — Pedunculated    Fibroid    Originating   in   the   Cervix   that   has   been 
Expelled  into  the  Vagina.     (After  Auvad.) 

When  removing  fibroids  by  operation  one  can  never  be  sure  that 
all  tumors  have  been  removed;  therefore,  a  patient  can  not  be 
assured  that  the  fibroids  will  not  grow.  On  the  other  hand, 
tumors  may  increase  rapidly  in  size.  Soft  tumors  grow  faster 
than  hard  ones,  as  a  rule.  Fibroid  tumors  grow  during  pregnancy 
and  diminish  in  size  markedly  after  delivery.  They  increase  in 
size  just  before  each  menstrual  period  and  diminish  after  the  flow 
has  ceased.  In  many  instances  they  lessen  in  size  after  the  meno- 
pause, but  not  always.  All  these  facts  must  be  kept  in  mind  when 
examining  a  patient  at  different  times  to  determine  the  relative 
bulk  of  a  tumor. 

DEGENERATIONS 

There  are  certain  alterations  of  structure  occurring  in  fibroids, 
the  causes  of  which  we  do  not  know,  except  that  sometimes  they 
can  be  explained  by  the  presence  of  arteriosclerosis  and  a  diminished 
blood  supply.  Degenerations  in  fibroids  are  observed  frequently 
following  pregnancy.  An  increased  formation  of  fibrous  and  hya- 


DEGENERATIONS  253 

line  tissue  occurs  in  practically  all  myomata  and,  when  the  process 
is  extensive,  necrosis  of  the  center  occurs,  with  a  resulting  cyst 
cavity  with  walls  of  irregular  outline. 

Softening  of  a  fibroid  tumor  may  be  due  to  several  causes. 
Among  them  we  may  enumerate  hyaline,  colloid,  and  fatty  de- 
generation. 

Hyaline  degeneration  was  noted  in  3.1  per  cent  of  2,274  cases 
of  fibroid  tumors  collected  by  Noble  from  the  literature  ("Gynecol- 
ogy  and  Abdominal  Surgery,"  H.  A.  Kelly  and  C.  P.  Noble,  1907, 
p.  669).  Often  these  tumors  become  progressively  indurated, 
especially  after  the  menopause. 

Colloid  or  Myxomatous  Degeneration. — This  is  characterized  by 
the  effusion  of  mucous  material  between  the  muscle  bundles,  the 
mucin  and  proliferation  of  round  cells  in  the  interstitial  tissue 
distinguishing  it  from  edema.  Noble  found  myxomatous  degen- 
eration in  3.4  per  cent  of  his  2,274  cases. 

Small,  hard  tumors  are  found  at  autopsies  on  old  women,  their 
presence  not  having  been  detected  during  life. 

Fibro-cystic  Tumors. — These  tumors  result  from  the  breaking 
down  and  liquefaction  of  areas  of  degeneration  in  fibroids  and  the 
fusion  of  different  foci  by  the  absorption  of  the  dividing  partitions. 
The  degenerated  areas  are  separated,  not  by  distinct  walls,  but  by 
portions  of  the  fibrous  structure  of  the  tumor.  These  tumors  are 
not,  as  formerly  thought,  a  separate  class  of  tumors. 

Doleris  (Archiv.  de  tocologie,  janv.  et  fev.,  1883,  pp.  1  and  364), 
noted  a  proliferation  of  connective  tissue  becoming  colloid  hi  a 
fibroid  tumor  during  pregnancy.  After  delivery  it  is  supposed 
that  the  diminution  in  the  size  of  a  fibroid  is  due  to  fatty  degen- 
eration. 

Calcification. — This  is  rather  a  rare  transformation  which  Noble 
(loc.  clt.}  fount!  in  1.7  per  cent  of  his  cases.  Deposits  of  phos- 
phate and  carbonate  of  lime  are  found  near  the  periphery  or  the 
center  of  the  tumor  and  make  either  a  bony  framework — not  true 
bone,  however — or  a  shell.  Rarely  is  the  tumor  solidified  to 
make  the  so-called  "uterine  stone."  Small  areas  of  calcification 
are  not  uncommon. 

Fatty  Degeneration. — Gusserow  ("Die  Neubildungen  des  Ute- 
rus." 1S86)  has  called  attention  to  the  fact  that  fatty  degeneration 
of  a  fibroid  tumor  has  been  determined  microscopically  in  only  three 


254          DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

cases — those  of  Freund,  A.  Martin,  and  Brunirigs — where  there  has 
not  been  resulting  diininution  in  the  size  of  the  tumor  as  well. 
There  is  a  form  of  fibroid  tumor  called  lipomyoma  in  which  a  por- 
tion of  the  tumor  is  composed  of  fatty  tissue. 

Edema. — Kdema  is  often  present  in  fibroids  and  may  be  con- 
sidered a  beginning  stage  of  necrosis.  It  most  often  affects  the 
subserous  tumors. 

Amyloid  Degeneration. — A  single  case  of  amyloid   degeneration 


FKJ.   IDS. — Fibroid  of   (ho  Cervix   Distending   the  Vagina.      (After   Durtigues.) 

of  a  fibroid  polypus  has  been  observed  by  Stratz.  (Zeit.  f.  Geburts. 
u.  dyn.,  1889,  Bd.  XVII.,  H.  1,  p.  80.) 

Suppuration.— This  is  the  result  of  the  infection  of  the  tumor 
with  bacteria  derived  from  the  intestinal  canal,  the  genital  tract, 
or  the  blood.  Prolonged  pressure  of  a  tumor  on  the  bowel,  or  an 
appendix  vermiformis  adherent  to  the  tumor,  may  permit  easy 
penetration  of  microorganisms.  Instrumental  or  digital  invasion  of 
the  uterine  cavity  for  exploration  or  curetting  may  infect  a  fibroid, 
especially  a  ^ubmucous  myoma. 

Gangrene. — (langrene  may  result  when  a  tumor  is  undergoing 
degeneration,  or  when  there  is  torsion  of  its  pedicle.  Micro- 


COMPLICATIONS  255 

organisms  may  or  may  not  play  a  part  in  the  necrobiotic  process. 
The  mechanism  of  the  process  is  obscure.  Extreme  torsion  of  a 
tumor,  causing  stasis  of  the  blood  supply  and  necrosis  or  gangrene, 
is  a  rare  complication  of  fibroid  tumors.  Zangemeister  thought 
that  the  fibroid  uterus  when  rotated  showed  commonly  (21  times 
to  3)  a  torsion  to  the  right  side. 

Thrombosis. — Thrombosis  of  the  blood-vessels  of  a  fibroid  may 
occur.  It  is  probable  that  the  tumor  is  tolerated  in  the  body  for 
a  long  time  after  the  blood  supply  is  cut  off  before  it  becomes  in- 
fected, just  as  in  cases  of  neglected  extra-uterine  pregnancy  in  the 
late  months. 

Sarcomatous  Degeneration. — This  occurred  in  two  per  cent  of  the 
cases  collected  by  Noble  (loc.  cit.},  and  Winter  (Zeits.  fur  Geburts. 
und  Gynakol.,  Bd.,  LVIL,  H.  1,  1906,  p.  19)  found  sarcoma  in 
4.3  per  cent  of  253  cases  of  fibroid  tumor  in  which  sections  were 
taken  systematically  from  different  parts  of  all  tumors. 

COMPLICATIONS 

Carcinoma  occurs  as  an  associated  lesion  in  fibroid  tumors,  not 
as  a  degeneration,  for  we  know  that  the  two  processes  are  distinct 
histologically,  with  the  exception  of  a  few  cases  of  adenomyoma 
where  cancer  has  been  described  as  springing  direct  from  the 
glands  within  the  tumor.  In  a  study  of  4,880  consecutive  cases 
of  fibroid  tumor,  Noble  (loc.  cit.)  found  that  cancer  was  present  in 
2.8  per  cent.  In  his  personal  experience  with  337  fibroids,  cancer 
of  the  corpus  was  present  in  2.6  per  cent,  and  cancer  of  the  cervix 
in  1.4  per  cent ;  hence,  as  women  not  the  subject  of  fibroid  tumor 
have  cancer  of  the  cervix  ten  times  to  one  for  cancer  of  the  corpus 
uteri,  he  concluded  that  there  is  a  causal  relation  between  fibroma 
and  cancer  of  the  body  of  the  uterus  (adeno-carcinoma  of  the 
endometrium). 

Metastases. — Fibroid  tissue  can  be  invaded  and  destroyed  by 
an  epithelial  growth.  The  most  frequent  combination  is  occurrence 
of  carcinoma  of  the  body  of  the  uterus  coincident  with  fibre-myoma. 
Sometimes  a  fibroid  tumor  includes  in  its  tissues  glandular  elements 
derived  from  the  ducts  of  Miiller  or  Wolff,  and  these  elements  are 
subject  to  a  carcinomatus  transformation.  X.  Bender  and  G. 
Lardennois  (Bull.  Nw.  Anal.,  1904,  No.  8,  Octobre)  have  shown 


250         DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

that  uterine  fibroids  may  be  invaded  by  metastases  from  cancer 
of  some  distant  organ. 

Diseases  of  the  Tubes  and  Ovaries. — These  diseases,  due  to  infec- 
tion, are  not  infrequent  complications  of  fibroids.  Daniel  studied 
this  subject  in  Pozzi's  clinic  (C.  Daniel,  Rev.  de  gyn.  et  de  chir. 
abd.,  1903,  pp.-  2-">  ot  193).  In  most  cases  either  the  ovaries,  or 
the  tubes  and  ovaries  together  were  diseased,  rarely  the  tubes 


FIG.   109. — Large  Globular  Fibroid,   the  Lower  Part  Filling  the  Cavity  of  the 
Pelvis,  Simulating  Pregnancy  at  Term.      (Kelly.) 

alone  were  affected.  Among  139  cases  gathered  from  the  litera- 
ture in  addition  to  his  own  cases  he  found  lesions  of  the  tubes  32 
times,  alterations  of  the  ovaries  alone  79  times,  and  tubo-ovarian 
disease  28  times.  Among  70  cases  observed  in  Pozzi's  clinic  the 
most  common  lesions  were  catarrhal  salpingitis,  purulent  salpin- 
gitis,  hematosalpinx,  and  cystic  degeneration  of  the  ovaries.  In 
Noble's  2,274  cases  of  fibroid  tumor  (loc.  cit.,  p.  668),  complications 
in  the  uterine  appendages  or  in  the  pelvis  existed  in  37  per  cent. 
In  Pozzi's  clinic  lesions  of  the  tubes  and  ovaries  occurred  in  r>9 
per  cent  of  the  myoma  cases. 


EFFECT  OF  FIBROID  TUMORS  257 

In  the  analysis  of  these  statistics  it  is  not  to  be  forgotten,  how- 
ever, that  these  large  percentages  were  among  women  whose 
fibroid  tumors  required  surgical  treatment;  they  had  entered  the 
hospital  for  operation.  It  is  hardly  fair  to  assume  that  all  fibroids 
are  subject  to  complications  to  the  same  extent;  in  fact,  this  is  an 
objection  to  most  of  the  statistics  which  have  to  do  only  with 
fibroid  tumors  causing  symptoms  of  a  severe  grade. 


EFFECT  OF  FIBROID  TUMORS  UPON  NEIGHBORING  ORGANS 

The  uterus,  being  attached  to  the  vagina,  to  the  uterine  liga- 
ments, and  to  the  peritoneum,  is  more  or  less  limited  in  its  move- 
ments. If  a  fibroid  tumor  develops  in  its  substance,  the  uterus 
may  displace  the  bladder  or  press  the  rectum,  urethra,  or  ureters 
against  the  bony  framework  of  the  pelvis.  In  the  case  of  a  fibroid 
of  the  posterior  uterine  wall,  the  cervix  may  press  on  the  urethra 
and  cause  retention.  But  this  is  a  rarity.  The  bladder  is  extremely 
tolerant  to  misplacement  by  a  tumor.  However,  retention  is  some- 
times caused  in  this  way,  and  congestion  of  the  vesical  mucosa, 
which  exists  in  the  case  of  fibroids  as  determined  by  Zukerkandl 
through  cystoscopic  examinations  (A.  Venot,  Annales  de  gyn.  et 
d'obstet.,  1907,  2  s.,  IV.,  287-310),  furnishes  a  favorable  soil  for  the 
growth  of  bacteria  that  may  be  introduced  by  a  catheter.  Injury 
of  the  ureters  and  kidneys  from  pressure  on  the  ureters  is  much 
more  frequent  than  thought  formerly.  Knox  has  reported  a  series 
of  cases  of  compression  of  the  ureters  observed  during  operation 
on  fibroids  at  the  Johns  Hopkins  Hospital.  Of  the  different  vari- 
eties intraligamentous  growths  and  tumors  developing  from  the 
cervix  are  most  apt  to  compress  the  ureters  and  also  to  displace 
them  upward. 

It  is  difficult  to  say  even  approximately  just  what  is  the  fre- 
quency of  renal  disease  because  of  ureteral  compression  by  fibroid 
tumors.  J.  C.  Webster  found  renal  complications  due  to  fibroids 
in  .30  per  cent  of  100  cases — on  the  other  hand,  Haultain  in  120 
cases  had  never  met  renal  complications.  Cullingworth  met  hydro- 
ncphrosis  due  to  compression  in  2  out  of  100  cases:  Sarwey,  1  in 
430  cases:  Knox.  3  in  400.  A.  Venot  points  out  that  the  com- 
pression of  the  ureter  is  probably  intermittent,  due  to  the  motion 

17 


258         DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

of  the  fibroid;  therefore  symptoms  due  to  the  compression  are  not 
present  with  any  definite  regularity. 

Interference  with  defecation  due  to  pressure  on  the  rectum  by 
a  fibroid  tumor  is  a  common  complication. 

Tumors  situated  low  cause  the  greatest  degree  of  interference 
with  the  enlargement  of  the  uterus  during  'pregnancy  and  with 
delivery.  Fibroids,  then,  are  a  cause  of  abortion.  Lefour  (These 
d'agreg.  dc  Paris,  1880),  out  of  307  cases  of  pregnancy  compli- 
cated by  niyomata,  noted  39  abortions  (12.7  per  cent),  the  mother 
dying  in  14  cases.  Nauss  (These  de  Halle,  1882),  out  of  241 
cases,  found  that  abortion  took  place  in  47,  or  15  per  cent.  The 
tumors  situated  low  in  the  pelvis  obstruct  delivery;  if  situated 
elsewhere  in  the  substance  of  the  uterus  they  generally  interfere 
with  involution  and  are  the  cause  of  post-partum  hemorrhages. 
Although  the  presence  of  a  fibroid  is  by  no  means  a  bar  to  the 
occurrence  of  pregnancy,  it  is  a  frequent  cause  of  sterility.  Ols- 
hausen  gathered  the  statistics  of  nine  different  observers,  including 
Scanzoni,  von  Winckel,  Schroeder,  and  Hofmcier,  and  found  that 
out  of  1,731  married  women  with  fibroid  tumors  520,  or  30  per  cent, 
were  sterile.  He  considers  this  figure  too  high,  however,  because 
many  women  with  fibroids  come  under  a  physician's  observation 
only  because  of  sterility,  and  those  who  become  pregnant  often  do 
not  consult  a  physician  at  all. 

EFFECT   ON   DISTANT   ORGANS  AND   ON   THE   SYSTEM 

Anemia  from  prolonged  and  repeated  hemorrhages  is  one  of  the 
most  common  results  of  fibroid  tumors.  The  hemoglobin  may  be 
reduced  as  low  as  thirty  per  cent  or  even  less  and  the  red  cells  to 
1,000,000.  The  affection  is  a  serious  one  and  difficult  to  correct 
often,  even  after  the  drain  of  blood  has  been  stopped.  Acute 
hemorrhage  in  fibroid  cases  seldom  proves  fatal,  but  the  continued 
loss  of  blood  produces  a  condition  of  lowered  vitality,  and  a  dis- 
position to  thrombosis,  embolism,  and  phlebitis  that  counter- 
indicates  in  many  cases  an  operation  for  the  removal  of  a  tumor. 
Many  authors  state  that  the  hemoglobin  should  be  at  least  fifty 
per  cent  before  a  hysterectomy  is  undertaken.  Kelly  and  Cullen 
however.,  (lor.  cit.,  pp.  453  and  454).  report  twenty-two  cases  of 
operation  for  the  removal  of  myomata  in  which  the  hemoglobin  was 


RELATION  OF  FIBROID  TUMORS  TO  HEART  DISEASE       259 

forty  per  cent  or  less,  with  a  mortality  of  three  cases.  It  often  hap- 
pens that  several  years  elapse  before  a  profoundly  anemic  patient 
regains  good  health  after  the  cause  of  the  loss  of  blood  has  been 
removed. 


RELATION  OF  FIBROID  TUMORS  TO  HEART  DISEASE 

The  frequency  of  cardiac  palpitation  hi  fibroid  tumors  has  been 
referred  to  by  me.  (Amer.  J&ur.  Obstet.,  Vol.  XXIX.,  No.  3,  1894.) 
The  symptom  appears  to  be  quite  independent  of  actual  cardiac 
disease,  there  being  no  evidences  of  enlargement  of  the  heart  or 
of  adventitious  murmurs.  It  is  possible  that  palpitation  may  be 
due  to  anemia,  in  which  event  one  expects  to  find  hemic  murmurs, 
and  some  influence  must  be  assigned  to  the  menopause  in  patients 
who  are  in  this  time  of  life.  (See  Chapter  XXIX.,  page  613.) 
The  exact  relation  of  these  tumors  to  heart  disease  is  not  known. 
Certain  degenerative  changes  in  the  heart  and  in  the  blood-vessels, 
such  as  brown  atrophy,  fatty  degeneration,  fatty  infiltration  of  the 
heart  muscle,  also  chronic  endocarditis,  and  arteriosclerosis  of  the 
arteries  have  been  noted  by  students  of  this  question,  notably  by 
Hofmeier,  Fenwick,  Strassman  and  Lehmann,  Boldt,  Pellanda,  Win- 
ter, and  Fleck,  as  quoted  by  Noble  (loc.  cit.,  p.  671).  Winter  found 
the  heart  perfectly  normal  in  60  per  cent  of  266  cases  examined 
with  reference  to  this  point;  valvular  disease  was  found  in  but  1 
per  cent,  and  dilatation  and  hypertrophy  in  but  6  per  cent,  the 
examinations  being  made  in  every  case  by  a  specialist  in  internal 
medicine. 

It  is  difficult  to  understand  how  lesions  of  the  heart  can  be 
caused  by  tumors.  I  think  we  may  agree  with  Winter  that,  in 
the  present  state  of  our  knowledge,  we  must  attribute  almost  all 
of  the  cardiac  symptoms  in  cases  of  fibroid  tumors  to  anemia,  and 
consequent  derangement  of  the  nervous  system.  It  is  well  to  re- 
member, however,  that  heart  disease  not  infrequently  accompanies 
fibroids,  although  not  necessarily  in  a  causal  relation. 


200         DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

DANGEROUS  TO  LIFE 

Fibroid  tumors  may  be  a  direct  menace  to  life.  Pellanda  (C. 
Pellanda,  "La  Mort  par  Fibromyomes  Uterins,"  Paris,  1905),  in  a 
study  of  171  cases  of  death  from  fibromyomata  without  operation, 
states  that  in  0.4  per  cent  of  the  fatal  cases  death  was  due  to 
hemorrhage. 

Acute  abdominal  emergencies  due  to  torsion  and  infection  of  a 
tumor  are  by  no  means  unknown.  Rupture  of  the  uterus,  due  to 
fibroids  obstructing  labor,  has  occurred.  As  a  rule,  however, 
these  tumors  endanger  life  indirectly  through  their  degenerations 
and  complications,  through  interference  with  the  function  of  other 
organs,  and  by  their  effect  on  the  general  health — anemia  and  its 
consequences. 

SYMPTOMS 

The  symptoms  of  fibroid  tumors  are  hemorrhage,  anemia,  pain, 
and  leucorrhca,  also  constipation,  frequency  of  micturition,  reten- 
tion of  urine,  and  dysuria;  the  last  four  being  the  result  of  pres- 
sure on  rectum,  ureters,  urethra,  or  bladder. 

Hemorrhage. — Hemorrhage  may  be  of  the  type  of  menorrhagia 
or  of  mctrorrhagia,  more  often  the  former.  It  is  a  symptom  met 
with  in  the  submucous  tumors,  occasionally  in  the  interstitial,  and 
not  at  all  in  the  subserous.  As  most  fibroids  are  multiple  it  is 
not  always  easy  to  say  which  form  predominates  in  any  given 
case.  The  submucous  varieties  cause  hemorrhage  by  enlarging 
the  surface  of  (he  endometrium,  the  total  number  of  square  inches 
being  increased  many  times  in  the  case  of  large  tumors. 

Diapedesis  of  red  blood  cells  through  the  walls  of  the  capillaries 
of  the  endometriuin  takes  place  to  a  greater  extent  the  larger  the 
surface  involved,  but  venous  congestion  caused  by  the  pressure 
of  the  tumor  on  the  thin-walled  veins  is  supposed  to  be  at  the  root 
of  the  mechanism  of  hemorrhage  in  fibroid  tumors;  the  arteries, 
with  their  thicker,  elastic  walls,  being  able  to  withstand  better  the 
pressure.  The  flowing  may  be  onlv  slightlv  increased  over  normal 
or  it  may  amount  to  an  excessive  hemorrhage  requiring  active 
treatment.  The  size  of  the  tumor  bears  no  relation  to  the  amount 
of  the  flow,  the  small  tumors  often  having  the  u'reatest  flowing. 


SYMPTOMS  261 

It  is  a  curious  fact  that  some  women  with  fibroids  flow  more  when 
they  are  lying  clown  than  they  do  when  up  and  about;  therefore 
the  treatment  in  such  cases  is  not  rest  in  bed.  This  peculiarity 
should  be  looked  for  in  getting  the  history.  An  active  acute 
hemorrhage  is  generally  not  so  serious  in  its  effects  on  the  system 
as  a  lesser  bleeding  lasting  over  months  and  years. 

Anemia. — Anemia  exists  so  frequently  in  fibroid  tumors  that  the 
physician  should  be  on  the  lookout  for  a  pale  face,  lips  without 
muca  color,  eyes  a  pearly  white,  muscles  rather  flabby,  pulse 
bounding,  but  soft  and  compressible,  with  increased  rapidity  on 
the  slightest  excitement.  Besides  palpitation  a  feeling  of  faint- 
ness  arid  breathlessness  and  languor  accompanies  anemia.  In  some 
cases  there  is  swelling  of  the  ankles.  The  red  blood  cells  may  fall 
to  one-fifth  or  less  of  the  normal  number  (1,000,000  per  cubic 
millimeter),  and  the  hemoglobin  to  thirty  per  cent.  Hemic  heart 
murmurs  are  usually  present. 

Pain. — Pain  may  or  may  not  be  present  in  fibroid  tumors,  and 
when  it  does  occur  is  variable  in  amount.  It  is  either  referred  to 
the  uterus  or  to  other  organs  when  due  to  pressure  on  surround- 
ing structures.  It  assumes  several  forms,  occurring  as  a  dull,  con- 
stant pain  situated  in  one  or  both  groins  or  across  the  abdomen, 
as  a  bearing-down  pain,  or  as  a  backache,  and  these  varieties  may 
exist  separately  or  conjointly.  It  may  be  referred  to  the  thighs  or 
the  legs  in  consequence  of  the  pressure  of  the  tumor  on  the  sacral 
plexus  of  nerves.  Pressure  on  a  ureter  may  cause  pain,  but  the 
rectum  and  bladder  arc  generally  tolerant  of  pressure  so  far  as  pain 
is  concerned,  their  disturbance  when  pressed  upon  showing  itself 
in  derangement  of  function.  Dysmenorrhea  occurs  in  about  twenty 
per  cent  of  the  cases  of  fibroid  tumors,  the  cramp-like  pain  being 
often  severe.  It  must  be  remembered,  however,  that  an  uncom- 
plicated fibroid  rarely  gives  rise  to  much  pain,  and  therefore  the 
presence  of  pain,  especially  if  severe,  indicates  an  inflammatory 
complication,  such  as  salpingitis  or  adhesions.  A  rapidly  grow- 
in";  tumor  is  apt  to  cause  pain  which  is  referred  to  the  uterus. 
Expulsive  pains  arc  found  when  a  submucous  tumor  becomes 
pedunculated  and  can  be  extruded  either  in  part  or  wholly  at  the 
external  os.  Kelly  and  Cullen  found  that  tumors  of  moderate  size 
caused  the  most  pain. 

Leucorrhea. — A  vaginal  discharge  is  rare  in  fibroids  except  in 


262         DIAGNOSIS  OF  FIBROID  TUMORS  OF  THE  UTERUS 

the  submucous  variety.  In  this  form  it  is  common  as  a  white 
discharge,  and  if  the  tumor  is  neerotic  the  discharge  is  muddy, 
watery,  and  malodorous.  A  profuse  watery  discharge  associated 
with  fibroids  should  always  excite  suspicion  of  cancer. 

Symptoms  of  Adenomyoma. — According  to  Cullen  this  variety 
of  myoma  is  most  prevalent  between  the  thirtieth  and  sixtieth 
years  and  does  not  tend  to  cause  sterility.  Lengthened  menstrual 
periods  arc  the  first  symptoms  and  the  flowing  gradually  assumes 
the  proportion  of  hemorrhages.  There  is  pain  with  the  period 
that  is  referred  to  the  uterus;  it  may  be  grinding  in  character. 
There  is  no  intermenstrual  vaginal  discharge  and  microscopical 
examination  of  scrapings  shows  the  uterine  mucosa  to  be  normal. 


DIAGNOSIS    AND    DIFFERENTIAL    DIAGNOSIS 

The  diagnosis  of  large  fibroid  tumors  is  a  comparatively  easy 
matter,  but  the  diagnosis  of  small  ones  is  often  difficult.  The 
symptoms  are  not  of  much  assistance,  except  that  painful  menstru- 
ation becoming  profuse  and  protracted,  and  a  history  of  sterility 
or  early  miscarriages,  are  suggestive  of  fibroids.  The  chief  reliance 
is  the  bimanual  palpation;  and  the  passage  of  the  uterine  sound  is 
most  useful.  The  first  point  to  determine  is  the  relation  of  the 
tumor  mass  to  the  body  of  the  uterus. 

Subserous  Fibroid  Tumors. — If  the  tumor  is  a  single  mass  bi- 
manual palpation  shows  that  it  is  connected  with  the  uterus. 
To  determine  this  point  place  the  tip  of  the  forefinger  in  the  vagina 
on  the  cervix.  On  moving  the  tumor  with  the  other  hand  on  the 
abdomen,  note  whether  the  cervix  moves  at  the  same  time.  Out- 
line the  growth  as  exactly  as  the  laxity  and  thinness  of  the  ab- 
dominal walls  will  permit.  In  some  cases  of  small-sized  tumors  in 
women  with  thin  parietes,  it  is  possible  to  map  out  the  ovaries, 
and  an  attempt  should  be  made  to  do  this  in  every  case.  If  the 
tumor  is  pedunculated  it  must  be  differentiated  from  an  ovarian 
cyxt.  This  is  done  by  detecting  fluctuation  in  a  cyst.  Making 
firm  pressure  against  the  tumor  with  the  finger  in  the  vagina,  taps 
with  the  finger  of  the  hand  on  the  abdomen  are  transmitted  to 
the  finger  in  the  vagina  as  waves.  The  pedicle  of  a  pedunculated 
myoma  may  be  palpated  by  drawing  down  the  cervix  with  a 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS  263 

vulsellum,  which  is  passed  to  an  assistant  to  hold  while  the  bi- 
manual  recto-abdominal  touch  is  practised.  (See  Fig.  126,  page 
301.)  If  the  contents  of  the  cyst  are  thick  and  semisolid,  as  in  the 
case  of  dermoid  cysts,  the  fluid  waves  will  be  absent.  Some  ova- 
rian cysts  are  as  hard  as  some  fibroids,  especially  soft  fibroids. 
As  a  rule  the  fibroids  are  multiple  and  there  is  more  than  one 
nodule  to  be  reckoned  with;  not  only  that,  but  the  nodules  are 
usually  of  a  stony  hardness.  If  the  fibroid  tumor  or  tumors  are 
large  enough  to  distend  the  abdomen  the  uterus  is  drawn  up  in  the 
pelvis.  This  upward  excursion  of  the  uterus  does  not  take  place  in 
the  case  of  an  ovarian  turmor. 

Fibroma  of  the  ovary  has  been  mistaken  for  a  pedunculated 
subserous  fibroid.  Here  only  an  abdominal  operation  can  clear  up 
the  diagnosis.  The  sound  should  be  passed.  Fibroids  are  so  often 
multiple  that  a  lengthened  canal  may  indicate  a  submucous  or  an 
interstitial  fibroid  and  therefore  indirectly  point  to  a  subserous 
tumor.  Before  passing  the  sound  observe  strict  antiseptic  precau- 
tions and  always  inquire  as  to  the  date  of  the  last  menstrua- 
tion. 

Pelvic  inflammatory  exudate  may  complicate  a  fibroid  tumor,  but 
is  seldom  mistaken  for  it.  The  mass  in  inflammation  is  brawny  and 
fills  in  the  chinks  of  the  pelvis.  There  is  a  history  of  fever,  even 
if  it  is  not  present  at  the  time,  as  shown  by  the  thermometer. 

Cancer  of  the  pelvis,  originating  in  the  uterus  or  ovaries,  may  be 
mistaken  for  fibroid  tumor,  but  is  differentiated  by  the  fixity  of 
the  infiltration,  and  the  lack  of  definite  outline  of  the  tumor. 

Ascites  is  occasionally  present  in  large  tumors.  Change  of  posi- 
tion of  the  patient  changes  the  situation  of  the  fluid,  which  is 
mapped  out  by  its  flatness  to  percussion. 

The  contour  of  the  abdomen  in  the  case  of  large  fibroids  is  dome- 
shaped  if  the  fibroid  is  globular  and  single,  nodular  if  multiple. 
The  tumor  stands  out  sharply  on  all  sides  when  seen  in. profile. 
(See  Fig.  103.)  Ascites,  if  it  is  present  in  excess,  modifies  the  contour. 

Intraligamentous  Fibroid  Tumors. — An  intraligamentous  fibroid 
is  situated  at  one  side  of  the  uterus,  the  sound  showing  the  situa- 
tion of  the  latter  if  it  can  not  be  palpated.  This  sort  of  tumor  is 
low  in  the  pelvis,  often  it  can  be  felt  projecting  into  the  vagina. 
Its  mobility  is  limited  because  of  its  attachments  and  its  situation. 

Interstitial    Fibroid    Tumors.— The    uterine    canal    is    commonly 


204         DIAGNOSIS   OF  FIBROID  TUMORS  OF  THE  UTERUS 

lengthened  in  cases  of  interstitial  fibroids,  and  hemorrhage  is  likely 
to  occur  in  these  tumors.  In  this  variety  the  enlargement  of  the 
uterus  may  be  symmetrical,  or  it  may  be  asymmetrical.  In  the  lat- 
ter, the  diagnosis  is  easier  to  make;  in  the  former,  one  must  rule 
out,  pregnancy.  To  do  this  it  is  important  to  get  the  history  most 
carefully,  having  regard  to  amenorrhea  and  nausea.  The  elastic 
feel  of  the  pregnant  uterus  is  to  be  sought  for,  also  the  softening  of 
the  cervix  and  the  bulging  of  the  anterior  segment  early  in  preg- 
nancy and  ballottement  later.  (See  Chapter  XXII.,  p.  423.) 
Breast  changes  are  to  be  looked  for,  and  if  the  tumor  is  large  an 
attempt  should  be  made  to  auscult  the  fetal  heart  sounds.  An- 
other examination  a  month  later  will  confirm  a  diagnosis  of  preg- 
nancy. 

A  fibroid  rarely  becomes  cystic  before  it  has  attained  the  size  of 
a  three  months'  pregnancy;  therefore,  an  elastic  tumor  of  less 
than  this  size  is  probably  not  a  fibroid.  The  sound  is  not  to  be 
passed  if  there  is  the  slightest  suspicion  of  pregnancy.  Examina- 
tion under  ether  is  advisable  if  the  abdominal  walls  are  tense  or 
the  conditions  for  examination  are  not  entirely  satisfactory. 

Sarcoma  may  develop  in  a  fibroid.  In  this  event  the  tumor  has 
grown  rapidly.  Only  operation  makes  a  positive  diagnosis  of  sar- 
coma, 

Submucous  Fibroid  Tumors. — A  history  of  hemorrhage  is  present 
in  almost  all  submucous  fibroids.  Here  the  diagnosis  is  established 
by  the  sound  and,  if  necessary,  by  digital  exploration  of  the  uterine 
cavity.  Birnanual  palpation  determines  an  increase  in  size  of  the 
uterus.  This  is  true  even  in  the  case  of  small  growths.  The 
sound  shows  enlargement  and  distortion  of  the  uterine  cavity. 
If  the  tumor  is  at  the  fundus  nothing  but  digital  exploration  will 
settle  the  question  whether  it  is  sessile  or  pedunculated.  Some- 
thing may  be  learned  often  by  the  tactile  sense  transmitted  through 
the  exploring  sound.  To  make  a  digital  exploration  of  the  uterine 
cavity  the  cervix  is  to  be  dilated  by  a  series  of  dilators:  the  Hanks, 
followed  by  the  Wathen  or  by  large  Simon  dilators,  plenty  of  time 
being  taken  so  that  rupture  may  not  occur.  In  cases  of  hard, 
resistant  cervices  it  is  best  to  adopt  the  method  of  incision  of  the 
anterior  wall  of  the  cervix  described  in  Chapter  ML,  page  94, 
repairing  the  cervix  by  suture  after  the  exploration  is  finished.  A 
sessile  submucous  fibroid  of  the  fundus  uteri  mav  be  mistaken  for 


DIAGNOSIS  AND  DIFFERENTIAL  DIAGNOSIS  265 

adenoma  or  adcno-carcinoma.  A  piece  removed  and  submitted 
to  microscopic  examination  is  the  only  means  of  distinguishing 
the  two.  A  pedunculated  tumor  presenting  at  the  external  os  may 
be  mistaken  for  inversion  and,  if  sloughing,  for  cancer  of  the  cervix. 
It  is  distinguished  from  cancer  by  learning  that  the  sound  may 
be  made  to  sweep  entirely  around  the  tumor,  thus  making  sure 
that  the  cervix  itself  is  not  the  seat  of  the  disease ;  and  from  inver- 
sion by  noting,  by  bimanual  recto-abdominal  touch  under  ether, 
that  the  fundus  uteri  is  in  its  normal  situation.  An  inverted 
uterus  is  usually  very  sensitive  to  touch,  although  not  invariably  so. 
Cancer  of  the  body  of  the  uterus  and  chorioepithelioma  are  to  be 
excluded  by  the  examination  of  tissue  removed  from  the  uterine 
cavity  by  curetting  or  by  digital  exploration,  and,  in  the  case  of 
chorioepithelioma,  by  the  history  of  a  previous  labor,  abortion, 
or  hydatidiform  mole  having  occurred  within  a  few  weeks. 


CHAPTER  XVI 

THE     DIAGNOSIS     OF     MALIGNANT    DISEASES    OF    THE 

UTERUS 

Cancer,  Sarcoma,  and  Malignant  Chorioepithelioma 

Cancer  of  the  uterus,  p.  20(5:  Definition,  p.  266.  Varieties,  p.  266. 
Diagnosis  of  cancer  of  uterus  in  general,  p.  270.  Diagnosis  of  cancer  of  the 
cervix,  p.  -271 ;  Differential  diagnosis  of  cancer  of  the  cervix,  p.  272. 
Diagnosis  of  adeno-careinoma  of  the  cervical  canal,  p.  275;  Differential 
diagnosis  of  the  adeno-carcinoma  of  the  cervical  canal,  p.  276.  Diagnosis 
of  cancer  of  the  body  of  the  uterus,  p.  276;  Differential  diagnosis  of 
cancer  of  the  body  of  the  uterus,  p.  277. 

Sarcoma  of  the  uterus,  p.  278:  Frequency  and  definition,  p.  278. 
Varieties,  p.  271). 

Malignant  chorioepithelioma.,  p.  280:  Definition,  macroscopic  and  mi- 
croscopic appearances,  p.  280.  Course  of  the  disease,  p.  281.  Ectopic 
malignant  chorioepithelioma.  p.  282.  Diagnosis,  p.  283. 


THE    DIAGNOSIS    OF   CANCER   OF   THE   UTERUS 

BY  cancer  of  the  uterus  we  understand  a  malignant  new  growth 
the  essential  ("lenient s  of  which  consist  of  epithelial  cells  having  a 
characteristic  arrangement.  The  cancer  cells  may  proliferate  and 
directly  invade  the  surrounding  tissues  or  they  may  be  transported 
by  the  lymphatics  to  distant  sites  and  there  proliferate  and  form 
metastatic  growths. 

VARIETIES 

The  mucous  membrane  of  the  uterus  may  be  divided  into  three 
types:  (1)  That  covering  the  vaginal  portion  of  the  cervix,  extend- 
ing from  the  vaginal  vault  to  the  external  os,  and  composed  of 
squamous-celled  epithelium.  (2)  That  lining  the  cervical  canal 
from  the  external  os  to  the  internal  os,  and  composed  of  high 
cylindrical  epithelial  cells;  and  (3)  That  lining  the  uterine  cavity 
proper  from  the  internal  os  to  the  fundus,  and  composed  of  low 

26(5 


CANCER  OF  THE  UTERUS  267 

cylindrical  or  cuboidal  epithelial  cells.  Cancer  of  the  uterus  al- 
ways originates  in  the  mucous  membrane,  and  the  type  of  cancer 
is  determined  by  the  character  of  the  cells  of  the  mucous  mem- 
brane in  which  it  originates. 

We  have  then  three  kinds  of  cancer  of  the  uterus: 

1.  Squamous-celled  cancer  of  the  cervix. 

2.  Adeno-carcinoma  of  the  cervical  canal. 

3.  Adeno-carcinoma  of  the  body  of  the  uterus. 


FIG.   110. — Early  Stage  of  Squamous-celled  Cancer  of  the  Cervix.     The  Cauli- 
flower Mass  has  been  Curetted  away.     (Cullen.) 

Very  rarely  there  is  present  a  squamous-celled  cancer  of  the 
body  of  the  uterus. 

I.  Squamous-celled  cancer  of  the  cervix  begins  at  or  near  the  junc- 
tion of  the  cervical  and  vaginal  mucous  membranes  at  the  external 
os.  Clinically,  three  types  are  recognized:  (a)  The  everting  or 
cauliflower  growth,  in  which  there  is  marked  proliferation  of  the 
cancer,  the  growth  spreading  to  and  involving  by  direct  extension 
the  vault  of  the  vagina.  (6)  The  infiltrating  type,  in  which  the 
external  contour  of  the  cervix  may  remain  normal,  the  growth 
extending  internally  deep  into  the  wall  of  the  cervix,  (c)  The 
uleerative  type,  in  which  ulceration  with  loss  of  cervical  tissue  takes 
place  early  and  proceeds  until  the  entire  cervix  is  eroded. 


268      DIAGNOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

The  squamous-celled  type  of  cancer  of  the  cervix  is  usually  of 
rapid  growth  and  it  soon  involves  the  surrounding  tissue's  and 
organs — the  bladder,  the  ureters,  and  rectum.  The  lymph  glands 
of  the  parametrium  and  the  iliac  glands  receive  the  cancer  by 
means  of  the  lymph  channels  and  themselves  take  up  the  disease. 

Microscopically  the  squamous-celled  type  begins  as  an  hyper- 
trophy of  the  pavement  squamous  epithelium  of  the  cervix.  The 
cells  themselves  hypertrophy  and  have  large  round  or  oval  vesic- 
ular nuclei  with  many  mitotic  figures.  These  cells  invade  the 


Fir,.   111. — Very  early  Adeno-Carcinoma  of  the  Cervical  Canal.     (Cvillen.) 

cervical  tissue  in  ah1  directions  and  without  any  typical  arrange- 
ment. 

'2.  Adeno-cardnoma  of  the  cervical  canal  originates  in  the  high 
cylindrical  epithelial  cells  lining  the  cervical  canal  and  the  glands 
of  the  cervical  canal.  This  type  of  cancer  of  the  cervix  spreads 
perhaps  less  rapidly  than  the  squamous-celled  variety,  although 
necrosis  takes  place  rather  early.  The  squamous-celled  variety 
seldom  spreads  beyond  the  level  of  the  internal  os,  but  the  adeno- 
carcinoma  frequently  reaches  to  the  fun* his.  The  cervix  may  be 
reduced  to  a  mere  shell  by  the  necrosis  of  the  latter  form  of  cancer 
and  yet  the  external  contour  of  the  cervix  remains  unchanged. 
Metastasis  to  the  surrounding  organs,  the  bladder  and  rectum. 


CANCER  OF  THE  UTERUS  269 

takes  place  usually  by  direct  extension  of  the  growth.  The  iliac 
glands  are  involved  sometimes  early  and  sometimes  late,  as  is  the 
case  with  the  squamous-celled  variety. 

Microscopically  adeno-carcinoma  of  the  cervix  is  recognized 
as  a  proliferation  of  the  cylindrical  cells  of  the  cervical  mucous 
membrane,  these  cells  preserving  their  alveolar  or  glandular  ar- 
rangement. There  is  distinct  loss  or  crowding  out  of  the  inter- 
glandular  stroma,  the  proliferating  alveoli  lying  close  to  one  another. 

3.  Adeno-carcinoma  of  the  body  of  the  uterus  originates  in  the 
low  columnar  epithelium  lining  the  uterine  cavity  and  the  glands 


fat  fatj 


FIG.   112. — Early  Adeno-Carcinoma  of  the  Body  of  the  Uterus.     (Cullen.) 

of  the  endometrium.  It  usually  starts  at  the  fundus  or  in  one 
cornu  as  a  circumscribed  area  of  proliferation  of  the  endometrium. 
From  this  point  it  may  spread  until  it  involves  the  entire  uterine 
cavity.  The  growth  may  proliferate,  forming  actual  outgrowths 
of  endometrium  into  the  uterine  cavity,  as  well  as  invade  the 
uterine  muscular  wall.  The  growth  may  ulcerate  its  way  through 
the  uterine  wall  and  appear  in  the  peritoneal  cavity  and  form 
peritoneal  metastases.  This  is  generally  a  late  process  of  a  long- 
existing  cancer.  The  ordinary  benign  uterine  polyp,  being  covered 
by  endometrium,  may  become  carcinomatous.  Adeno-carcinoma 


270     DIAGNOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

of  the  body  seldom  extends  beyond  the  internal  os,  although  adeno- 
carcinoma  of  the  body  and  cervix  may  coexist. 

Glandular  metastasis  from  this  form  of  cancer  is  late. 

Microscopically  adeno-carcinoma  of  the  body  is  recognized  by 
the  proliferation  of  the  low  cylindrical  cells  of  the  endometrium 
of  the  fundus,  these  cells  preserving  their  glandular  arrangement 
with  distinct  loss  of  interglandular  stroma.  The  cells  lining  the 
new  glands  are  from  two  to  four  layers  deep  or  possibly  entirely 
fill  the  alveolus. 

DIAGNOSIS  or  CANCER  OF  THE  UTERUS  IN  GENERAL 

It  is  important  to  keep  in  mind  that  cancer  is  always  a  local 
disease  in  the  beginning  and  that  prompt  removal  of  the  diseased 
tissues  effects  a  permanent  cure ;  therefore  early  diagnosis  is  espe- 
cially important.  A  failure  to  make  a  correct  diagnosis  is  followed 
surely  by  the  death  of  the  patient  in  from  six  months  to  a  year 
and  a  half.  Late  operations,  except  in  the  case  of  cancer  of  the 
body,  are  of  value  only  in  prolonging  life  a  few  months  or  a  year 
or  two,  and  in  lessening  suffering.  The  view  commonly  held  by 
the  laity,  and,  sad  to  relate,  by  too  many  of  the  medical  profession, 
that  cancer  is  an  incurable  disease  is  not  true,  provided  that  it 
can  be  recognized  and  removed  before  it  has  gained  a  good  head- 
way. 

It  appears  that  progress  is  being  made  in  getting  patients  to 
submit  to  examination  at  earlier  periods  of  the  disease.  G.  Win- 
ter's works  in  spreading  a  propaganda,  both  among  the  physicians 
and  the  laity,  in  East  Prussia,  is  most  encouraging  (Zentralblatt  fur 
Gymikoloyie,  1904,  No.  14,  p.  441).  It  is  a  fact,  however,  that  at 
the  present  time  a  large  proportion  of  the  sufferers  from  this  dread 
disease  are  permitted  to  get  into  an  absolutely  hopeless  state,  then 
to  go  through  the  awful  months  of  suffering  until  a  lingering  death 
releases  them. 

The  xymjrtoms  of  uterine  cancer  are  by  no  means  pathognomonic ; 
they  are  suggestive  and  an;  as  follows:  Bleeding,  particularly  in 
women  who  have  passed  the  menopause;  and  hemorrhage  or  a 
show  of  blood  after  coitus,  also  a  persistent  or  recurring  sero- 
sanguinolent  vaginal  discharge.  Neither  of  these  is  a  symptom 
of  the  normal  menopause,  as  has  been  maintained  in  the  past.  The 


CANCER  OF  THE  UTERUS  271 

menopause  has  no  local  symptoms  if  the  uterine  organs  are  normal. 
Bleeding  or  a  vaginal  discharge  occurring  at  the  time  of  change  of 
life  should  lead  at  once  to  a  vaginal  examination  to  determine  the 
cause.  Pain  and  cachexia  are  symptoms  of  the  advanced,  hope- 
less stages  of  the  disease,  only  at  this  time  one  does  not  have  to  be 
a  physician  to  make  a  diagnosis.  Although  the  disease  occurs 
most  commonly  in  women  who  are  between  the  fortieth  and  fiftieth 
years  it  may  occur  at  any  age  between  eight  and  seventy-six. 

Clinically,  heredity  seems  to  play  a  role,  though  this  has  been 
disputed. 

The  disease  is  relatively  rare  in  the  colored  race. 

It  is  more  frequent  among  women  who  have  borne  children  than 
in  nulliparaB. 

The  diagnosis  varies  with  the  progress  of  the  disease,  and  the 
variety  of  cancer  present ;  the  early  stages,  while  the  normal  tissues 
are  being  replaced  by  cancer  cells,  show  only  a  slight  local  thicken- 
ing or  proliferation ;  the  later  stages,  when  the  tissues  are  breaking 
down  and  degenerating,  show  ulceration,  bleeding,  and  detritus 
with  foul  odor. 

As  has  been  pointed  out  in  describing  the  different  forms  which 
cancer  assumes,  the  disease  advances  in  different  manners  and  at 
different  rates  of  speed  in  individual  cases.  It  may  progress  to  a 
fatal  termination  in  a  year;  on  the  other  hand,  I  have  had  a  patient 
who  had  the  erosion  type  of  cancer  of  the  cervix  where  there  was 
every  indication  that  the  disease  had  existed  for  twenty  years. 
The  tissues  may  be  brittle  and  easily  disintegrating,  or  tough  and 
hard.  The  tissues  most  commonly  invaded  by  the  different  kinds 
of  cancer  have  been  noted,  therefore  in  making  a  diagnosis  the 
routes  of  extension  of  the  disease  must  be  taken  into  account. 
We  employ  both  touch  and  sight  in  making  a  diagnosis,  as  well 
as  microscopic  examination  of  tissues  removed. 

DIAGNOSIS  OF  CANCER  OF  THE  CERVIX 

This,  of  all  forms  of  uterine  cancer,  is  the  easiest  of  diagnosis 
because  the  lesions  can  be  detected  by  both  touch  and  sight. 

(a]  The  caulijlnu'er  yrinrth  is  the  simplest,  growing  as  it  does  as 
a  polyp-like  mass  projecting  from  the  cervix  into  the  vagina.  In 
the  early  stages  this  appears  as  an  indurated,  reddened  area  raised 


272     DIAGNOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

above  the  surrounding  mucous  membrane.  In  its  later  progress 
one  expects  to  find  a  larger  tumor,  reddish-gray  in  color,  with 
softened,  disintegrated  tissue.  The  sound  perforates  it  with  ease, 
and  any  manipulation  causes  hemorrhage. 

(6)  If  the  infiltrating  sort  is  present  the  tissues  are  indurated  and 
the  contour  of  the  cervix  may  be  altered  or  not.  If  the  vaginal 
mucous  membrane  overlying  the  growth  is  intact  the  diagnosis 
is  difficult.  In  all  suspicious  cases  a  wedge-shaped  piece  of  tissue 
should  be  removed  and  submitted  to  the  pathologist  for  micro- 
scopic examination. 

(r)  The  -ulcerating  variety  is  distinguished  by  an  ulcer  of  exca- 
vating tendency.  There  is  much  loss  of  substance;  the  edges  of 
the  ulcer  arc  rough  and  irregular;  the  base  is  necrotic;  the  under- 
lying tissues  are  hard  to  the  feel.  If  portions  of  the  deeper  parts 
of  the  edge  of  an  ulcer  crumble  on  pressure  by  the  finger  or  sound 
the  condition  is  suspicious  of  cancer;  also,  if  the  edge  of  the  ulcer 
has  a  porky  consistency  and  is  of  a  yellowish-gray  color.  In  all 
doubtful  cases  a  piece  of  tissue  must  be  removed  for  microscopic 
examination.  To  do  this  fix  the  cervix  with  a  double  tenaculum 
just  outside  the  diseased  area  and  let  an  assistant  hold  the  tenacu- 
lum. If  the  cervix  proves  to  be  sensitive  inject  into  the  sound 
tissue  surrounding  the  diseased  area,  in  several  places,  a  few  minims 
of  two-per-cent  sterile  solution  of  cocaine  with  a  hypodermic 
syringe.  \Yait  five  minutes.  With  a  single  tenaculum  and  a 
scalpel  or  scissors  cut  out  a  good-sized  piece  of  the  diseased  tissue 
in  the  shape  of  a  wedge.  Be  prepared  to  place  a  catgut  stitch 
with  a  curved  needle  should  there  be  much  bleeding.  Often  an 
application  of  tincture  of  iodine  and  carbolic  acid  followed  by  a 
dry  tampon  will  be  sufficient  to  stop  all  bleeding.  The  patient 
should  not  be  dismissed  until  it  is  known  that  the  bleeding  has 
been  controlled. 

Differential  Diagnosis  of  Cancer  of  the  Cervix 

(a)  Cauliflower  Form. — The  cauliflower  form  of  cancer  of  the 
cervix  must  be  differentiated  from: 

(1)  Follicular  hypcrtrophic  polyp. 

(2)  Mucous  polyp. 

(3)  Papillary  tuberculosis. 


CANCER  OF  THE  UTERUS  273 

(4)  Myoma  of  the  cervix. 

(5)  Condylomata  acuminata. 

(1)  The  follicular  hypertrophies  of  the  cervix  produce  discrete 
tumors,  in  some  cases  similar  to  polypi.     They  are  soft,  of  a  red 
color,  and  show  the  rounded,  yellow,  shot-like,  dilated  Nabothian 
follicles  in  their  substance,  the  condition  being  not  unlike  that  in 
the  tonsil.     The  follicles  may  be  seen  and  felt  also  in  the  surround- 
ing normal  mucous  membrane  of  the  cervix.     There  is  lacking  the 
crumbling  consistency,  the  sharp  edges,  and  the  indurated  base 
of  the  cauliflower  cancer.     The  microscope  will  confirm  the  diag- 
nosis. 

(2)  Mucous  polypi,  especially  if  multiple  and  having  a  lumpy 
appearance,  may  be   mistaken   for   cancer.     Polypi   are   covered 
everywhere  with  mucous  membrane,  they  are  soft,  and  the  sound 
will  detect  the  position  and  size  and  shape  of  their  pedicles. 

(3)  Papillary  tuberculosis,  although  relatively  rare,  may  simulate 
closely  polypoid  carcinoma  in  its  early  stages.     The  external  os 
may  be  surrounded  by  a  papillary  excrescence.     It  is  possible  in 
favorable  cases  to  determine  the  presence  of  the  little  glassy  tuber- 
cles the  size  of  a  millet  seed  lying  in  the  greasy,  cheesy  substance 
characteristic  of  broken-down  tuberculous  tissue.     In  tuberculous 
disease  of  the  cervix  the  ulcerated  form  is  more  common  than  the 
papillary.     The  diagnosis  must  be  made  by  the  microscope. 

(4)  Myoma  of  tlte  cen'ix  is  rare.     A  cervical  myoma  is  covered 
with  a  smooth  mucous  membrane,  it  disintegrates  by  ordinary 
gangrene,  and  has  a  firm  arid  not  a  crumbly  consistency. 

(o)  Pointed  condylomata  may  simulate  papillary  cancer,  especially 
during  pregnancy.  They  form  a  circumscribed  tumor  of  irregular 
surface;  but  they  have  no  infiltrated  base  and  no  real  ulceration, 
only  a  papillary  surface  with  thick  epithelium.  They  are  of  a 
reddish-white  color.  As  a  rule  they  occur  in  more  than  one  situa- 
tion at  the  same  time,  i.e.,  on  the  wall  of  the  vagina  or  on  the  vulva. 

(1)}  Infiltrating  Cancer. — Infiltrating  cancer  is  confused  most  often 
with  inflammatory  diseases  of  the  cervix  occurring  in  connection 
with  tears,  especially  when  the  tissues  are  indurated  and  nodular, 
as  they  often  are.  As  a  rule  the  inflammatory  process  involves 
the  entire  cervix,  the  consistency  is  not  so  hard  as  in  cancer,  and 
the  external  mucous  membrane  is  not  involved.  If  the  cervix  is 
riddled  with  diseased  Xabothian  follicles  the  similarity  of  the  two 
13 


274     DIAGNOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

conditions  is  often  great.  But  here  the  cancer  is  limited,  whereas 
the  inflammatory  affection  is  universal.  In  all  cases  a  piece  of 
tissue  should  be  removed  for  examination. 

(c)  Ulcerating  Form. — The  ulcerating  form  of  carcinoma  must  be 
differentiated  from : 

1.  Erosion. 

2.  Simple  ulcer;  as  in  prolapse. 

3.  Tuberculous  ulcer. 

4.  Chancroids. 

5.  Syphilitic  ulcer. 

1.  If  there  is  very  little  infiltration  and  induration  a  cancerous 
ulceration  may  simulate  a  simple  erosion,  especially  in  those  cases 
where  the  erosion  has  a  thick,  roughened  surface.  The  character- 
istics of  the  malignant  ulceration  are  to  be  borne  in  mind.  Also, 
the  erosion  as  seen  through  the  speculum  presents  a  bright  red, 
shining  appearance,  while  the  cancerous  ulceration  shows  loss  of 
substance  and  a  dull  red  or  yellowish-gray  color. 

The  erosion  has  no  sharp  edge,  but  shows  a  gradual  transition 
of  the  pavement  epithelium  of  the  normal  mucous  membrane  to 
the  erosion  by  a  border  of  irregular  outline,  and  there  are  apt  to 
be  islands  of  normal  mucous  membrane  in  the  erosion.  If  there 
is  infection  of  the  erosion,  scar  formation  results.  In  doubtful 
cases  the  microscope  must  be  brought  in. 

(2)  Simple  Ulcers. — These  occur  in  prolapse;  they  are  generally 
not  situated  at  the  external  os,  while  the  carcinomatous  ulcers  are 
more  apt  to  be  in  that  situation.     They  are  apt  to  have  a  light 
yellow  base  and  show  cicatrization  about  the  periphery,  and  there 
are  islands  of  mucous  membrane  in  the  central  portions.     After 
the   prolapsed    uterus   has   been    replaced    for   a   day,   all  traces 
of   infiltration    of  the  tissues   under  such   ulcers  disappear  and 
evidences  of  repair  at  the  edges  can  be   seen.     As   a   rule  there 
is  little  or  no  thickening  of  the  tissues  under  these  ulcers.     This 
is  the  case  also  with  ulcers  caused  by  an  ill-fitting  pessary.     They 
heal  readily. 

(3)  Tuberculous  Ulcer. — This,  although  rare,  is  very  similar  to 
carcinomatous    ulcer.     Both    are    generally    situated    around    the 
external  os;  the  base  of  the  tuberculous  ulcer  is  yellow  in  color, 
nodular   but   not   infiltrated.     Yellow,   miliary  tubercles   may   be 
seen  in  the  mucous  membrane  in  the  neighborhood  of  the  ulcer. 


CANCER  OF  THE  UTERUS  275 

There  Ts  apt  to  be  present  also  tuberculosis  of  the  endometrium 
and  of  the  tubes.     The  microscope  settles  the  diagnosis. 

(4)  Chancroids  are  generally  small  in  size  and  multiple;  their 
base  has  a  diphtheritic,  grayish  appearance,  and  is  not  indurated, 
and  the  edges  are  indented  and  raised.     Similar  lesions  are  to  be 
found  generally  in  the  vagina  and  vulva. 

(5)  Syphilitic  ulcer  may  occur  on  the  cervix  in  three  forms:  (a) 
as  an  ulcerated  initial  lesion,  (6)  as  broken-down  papules,  or  (c)  as 
a  degenerated  gumma. 

(a)  The  initial  lesion  is  solitary  and  of  great  hardness.  The 
ulcer  has  a  sharp  edge  and  is  of  a  dirty  reddish-brown  color;  its 
discharge  being  of  a  greasy  consistency.  It  may  extend  into  the 
cervical  canal  in  the  case  of  a  parous  woman  with  open  os  externum. 

(6)  Ulcers  from  papules  are  generally  multiple  and  are  elevated 
above  the  surrounding  surface  of  the  normal  mucous  membrane. 
Their  surface  is  covered  with  disorganized  white  or  yellowish  tissue. 
Near  them  are  to  be  found  non-ulcerated  papules,  especially  on 
the  walls  of  the  vagina  and  vulva. 

(c)  Gummata  of  the  cervix  are  very  rare.  They  are  described  by 
Neumann  (Winter's  "  Lehrbuch  der  Gynakologischen  Diagnostik," 
iii.  Auf.)  as  occurring  about  the  os  externum  and  on  either  or  both 
the  anterior  and  posterior  lips  of  the  cervix.  The  ulcers  are  ellip- 
tical in  shape  with  sharply  defined  edges,  shallow  or  deep,  generally 
with  yellow  purulent  covering.  Good-sized  fungous  granulations 
are  apt  to  be  found  on  the  surface.  These  ulcers  are  to  be  differ- 
entiated from  cancerous  ulcerations  by  their  irregular  and  sinuous 
borders,  their  rapid  disintegration,  and  the  crater-like  excavations 
of  their  tissues.  Syphilitic  lesions  elsewhere  in  the  body  assist  in 
making  the  diagnosis,  the  microscope  being  the  court  of  last  resort. 

DIAGNOSIS  OF  ADEXO-CARCIXOMA  OF  THE  CERVICAL  CANAL 

In  this  form  the  diagnosis  is  of  necessity  difficult.  Palpation 
will  show  usually  thickening  of  the  cervix  and  perhaps  a  nodular 
feeling.  If  the  external  os  is  normal,  a  nodular  thickening  and  the 
detection  of  a  bloody  discharge  from  the  os  may  be  all  of  the  sus- 
picious signs. 

If  the  os  is  open  because  of  tears,  ulcerated  and  indurated  areas 
in  the  canal  may  be  both  palpated  by  the  finger  in  the  canal  and 


276      DIAGNOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

seen  with  a  uterine  or  bladder  speculum.  With  the  aid  of  a  sharp, 
stiff-shanked  curette,  tissue  is  removed  for  microscopic  examination. 

In  the  infiltrating  variety  where  there  is  no  ulceration,  palpation 
having  shown  localized  thickening  of  the  tissues,  the  external  os 
should  be  dilated  under  ether  and  a  piece  of  tissue  excised  for  a 
microscopic  examination. 

In  curetting  the  body  and  fundus  of  the. uterus  it  is  very  easy 
to  overlook  this  situation.  The  physician  should  bear  in  mind 
always  that  the  cervical  canal  is  one  of  the  points  of  origin  of 
cancer. 

Differential    Diagnosis  of  Adeno-carcinoma  of  the  Cervical  Canal 

This  form  of  cancer  of  the  uterus  is  to  be  differentiated  from 
interstitial  myoma,  and  chronic  cervical  endometritis  in  old  women. 

As  to  the  former,  the  infiltration  of  the  tissues  surrounding  the 
center  of  the  disease  distinguishes  carcinoma  from  myoma.  In 
the  case  of  the  latter  the  mucous  membrane  of  a  chronic  endocervi- 
citis  is  more  normal  to  sight,  although  not  necessarily  so  to  the 
touch,  and  the  curette  carries  away  little  tissue.  Tissue  is  removed 
and  the  microscope  tells  the  last  word. 

DIAGNOSIS  OF  CANCER  OF  THE  BODY  OF  THE  UTERUS 

(A  D  E  X  ( )-C  ARC  I  NO.M  A) 

The  symptoms  are  the  chief  guide  to  a  diagnosis  of  cancer  of 
the  body  of  the  uterus.  Bleeding  alternating  with  a  watery  dis- 
charge, occurring  in  a  woman  who  is  past  the  menopause,  and  the 
exclusion  of  fibroids  and  of  cancer  of  the  cervix,  make  cancer  of 
the  body  probable.  Cancer  of  the  body  of  the  uterus  is  more  com- 
mon in  nulliparze  than  in  women  who  have  borne  children.  There 
is  sometimes  a  characteristic  odor  to  the  uterine  discharge  in  cancer. 
It  can  not  be  described,  however.  A  recurrent  pain,  similar  to 
labor  pains,  coming  on  regular  days  and  of  several  hours'  duration, 
the  so-called  Simpson  symptom,  has  been  described  as  character- 
istic of  cancer  of  the  body.  This  sort  of  pain  is  found  also  in  myoma 
of  submiieous  evolution  and  must  be  interpreted  as  the  result  of 
the  stimulation  of  the  uterus  by  a  foreign  body  which  it  is  trying 
to  expel.  There  is  nothing  characteristic  in  the  uterine  discharge 
of  cancer  to  distinguish  it  from  the  discharge  from  myoma,  except 


CANCER  OF  THE  UTERUS  277 

that  on  microscopic  examination  cancer  elements  may  be  dis- 
tinguished in  it.  A  uterine  discharge  occurring  in  a  woman  past 
forty  should  lead  to  an  investigation. 

So,  also,  palpation  gives  no  characteristic  feeling.  There  should 
be  slight  enlargement  of  the  body;  there  may  be  tenderness.  In 
patients  with  very  thin  or  lax  abdominal  walls  it  may  be  possible 
in  exceptional  cases  to  make  out  a  localized  tumor  in  the  body 
of  the  uterus.  This  is  unusual. 

The  diagnosis  is  established  by  exploration  of  the  cavity  of  the 
uterus,  first  with  the  sound  and  then  with  the  curette  forceps  or 
the  finger.  The  sound  will  detect  friable  tissue,  the  curette  forceps 
will  remove  it  for  microscopic  examination.  Every  part  of  the 
uterine  cavity  must  be  reached  by  the  curette,  as  the  initial  lesion 
may  be  very  small  and  easily  overlooked. 

The  curette  forceps  are  especially  valuable  in  this  case,  for  they 
pinch  off  and  remove  tissue  without  tearing  it  to  pieces.  The  finger 
introduced  to  the  fundus  can  recognize  beginning  cancer  of  the 
mucous  membrane. 

In  order  to  examine  with  the  finger  ether  must  be  administered 
and  the  cervix  dilated  with  steel  branched  dilators  and  large  Hegar 
dilators.  A  method  devised  by  H.  A.  Kelly,  consisting  of  an  an- 
terior colpotomy  and  division  of  the  anterior  wall  of  the  cervix 
(see  page  94),  is  of  value  often  in  exploring  the  interior  of  the 
uterus.  As  in  the  other  forms  of  uterine  cancer,  the  microscope  is 
the  means  of  a  sure  diagnosis. 

Differential  Diagnosis  of  Cancer  of  the  Body  of  the  Uterus 

The  differential  diagnosis  is  a  matter  of  the  microscopic  exami- 
nation. The  physician  should  remember  that  sarcoma  of  the  endo- 
metrium,  necrotie  myoma,  mucous  polypi,  the  products  of  concep- 
tion, or  hydatidiform  moles  may  be  found  in  the  uterine  cavity. 
The  characteristics  of  cancer  of  the  fundus  have  been  referred  to 
already  (page  269). 

Before  leaving  the  subject  of  uterine  cancer  it  is  well  to  draw  at- 
tention to  the  great  difficulty  often  experienced  in  determining 
whether  a  thickening  in  the  broad  ligaments  is  of  inflammatory  or 
of  cancerous  origin.  It  is  well  to  boar  in  mind  that  most  thicken- 
ings arc  the  result  of  old  pelvic  inflammation.  Cancer  may  super- 


278      DIAGNOSIS  OF  MALIC1XAXT  DISEASES  OF  THE   UTERUS 

vene,  however,  and  then  it  may  be  assumed  that  all  of  the  indura- 
tion is  due  to  the  cancerous  infiltration.  The  history  of  the  case 
is  of  some  assistance  in  differentiating  the  two. 

If  there  has  been  pelvic  inflammatory  disease,  it  will  be  shown 
by  a  history  of  difficult  and  infected  labors  and  abortions  and  a 
history  of  old  attacks  of  "inflammation  of  the  bowels."  We  have 
seen  what  are  the  usual  routes  of  infection  of  the  surrounding 
tissues  in  the  different  forms  of  uterine  cancer,  both  as  to  the  cellu- 
lar tissue  and  the  glands.  Then  we  know  that  cancer  of  the  body 
seldom  extends  to  the  broad  ligaments  and  to  the  lymphatic  glands 
except  in  the  late  stages  of  long  neglected  cases,  whereas  cancer  of 
the  cervical  canal  extends  to  the  surrounding  tissues  relatively 
early. 

THE  DIAGNOSIS  OF  SARCOMA  OF  THE  UTERUS 

Sarcoma  of  the  uterus  is  of  very  rare  occurrence.  It  is  most 
often  found  between  the  ages  of  forty  and  sixty.  W.  A.  Edwards 
(Amer.  Jour.  Med.  Sci.,  July,  1909)  has  recently  collected  16  cases 
of  sarcoma  of  the  uterus  in  children  who  were  fifteen  years  of  age 
or  younger.  It  forms  about  4.8  per  cent  of  all  malignant  growths 
and  2  per  cent  of  all  uterine  tumors.  (E.  Hurdon,  Kelly  and  Noble, 
"Gynecology  and  Abdominal  Surgery,"  Vol.  I.,  p.  151.)  It  is  a 
disease  originating  from  connective-tissue  elements  as  contrasted 
with  epithelial  elements  from  which  carcinoma  arises.  There  is  to 
be  noted  in  sarcoma  not  only  a  numerical  increase  in  the  number 
of  cell  elements,  a  hypcrplasia,  but  also  a  change  in  the  original 
type,  heteroplasia.  The  small  round  or  spindle  cells  acquire  large 
nuclei,  many  times  larger  than  the  nuclei  of  the  original  cells  of 
the  connective  tissue.  There  is  great  proliferation  of  the  cells 
into  the  surrounding  tissues  and  later  metastases  by  the  blood- 
vessels to  distant  organs.  The  proliferation  is  not  everywhere 
uniform:  larger  and  smaller  cells  lie  together,  so  that  the  distin- 
guishing characteristics  of  sarcoma  are  the  change  in  the  type  of 
the  cells  and  the  dissimilarity  of  their  arrangement.  In  sarcoma 
the  tumor  parenchyma  is  richly  vascuiarized,  carrying  its  own 
blood  supply;  whereas  in  cancer  the  blood-vessels  are  contained 
only  in  fibrous  septa.  Therefore  sarcomata  are  full  of  blood  and 
are  not  so  apt  to  be  found  in  a  degenerated  condition. 


SARCOMA  OF  THE  UTERUS  279 

Three  varieties  are  recognized  by  pathologists:  spindle-celled 
sarcoma;  giant-celled  sarcoma;  and  small  round-celled  sarcoma. 
The  last  is  the  most  difficult  to  diagnose  microscopically,  especially 
if  only  small  pieces  are  furnished  from  a  curetting.  The  disease 
may  originate  in  any  of  the  structures  of  the  uterus  where  con- 
nective tissue  is  found,  in  the  interglandular  connective  tissue  of 


FIG.   113. — Round-celled  Sarcoma  of  the  Body  of  the  Uterus.     (Cullen.) 

the  endometrium,  in  the  connective  tissue  of  the  myometrium, 
or  about  the  blood-vessels.  One  of  the  most  frequent  seats  is  a 
preexisting  myoma  of  submucous  or  interstitial  development; 
the  next  most  frequent  is  the  body  of  the  uterus,  and  the  least 
frequent  is  the  cervix. 

In  sarcoma  of  tJie  body  of  the  uterus,  if  the  disease  originates  in 
the  endometrium,  there  is  a  diffuse  thickening  and  infiltration  of 
the  endometrium,  accompanied  often  by  more  or  less  definitely 


2SO     DIAGNOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

circumscribed  outgrowths.  The  growth  is  soft  and  friable,  con- 
sisting of  a  homogeneous  bruin-like  substance  very  well  vascular- 
izcd. 

Sarcoma  of  the  muscular  wall  usually  occurs  as  a  circumscribed, 
nodular  growth  and  rarely  as  a  diffuse  infiltration. 

Sarcoma  of  the  cervix  occurs  in  two  forms,  a  polypoid  tumor  of 
soft  consistency  and  smooth  surface,  attached  by  a  broad  base, 
or  a  tumor  made  up  of  many  little  blebs  of  tissue  of  different  sizes, 
racemose  in  character,  something  like  a  hydatidiform  mole  or  the 
grape-like  vaginal  sarcomata  of  infants.  These  latter  tumors  are 
sometimes  called  myxosarcomata. 

The  diagnosis  of  sarcoma  can  not  be  made  without  the  aid  of  the 
microscope.  Metastases  by  way  of  the  blood  current  occur  in 
about  a  fourth  of  the  cases  of  sarcoma  of  the  endometrium,  accord- 
ing to  G.  Winter.  They  are  in  the  lungs,  intestine,  arid  peritoneum. 
The  lymph  glands  are  very  seldom  involved.  Metastases  from 
sarcomata  of  the  uterine  wall  or  myomata  invaded  by  sarcoma 
are  more  frequent,  being  found  in  the  lungs,  liver,  and  intestine. 


THE    DIAGNOSIS   OF    MALIGNANT   CHORIOEPITHELIOMA 

Sunger  in  1889  (M.  Siinger,  "Ueber  Dedduome,"  Centralb.  f.  Gyn., 
1889,  Bd.  13,  p.  132)  reported  a  case  of  deciduosarcoma:  a  tumor 
developing  in  the  uterine  cavity  after  pregnancy  and  followed  by 
metastases  to  distant  organs.  Soon  other  observers  reported 
similar  tumors  under  the  names,  Deciduoma  malignum,  Deciduo- 
sarcoma, Placentoma,  Syncytioma  malignum,  Malignant  hydatidi- 
form mole,  or  other  names. 

Marchand  (F.  Mart-hand,  "Ueber  das  maligne  Chorioepitheliom 
nebst  Mittheilung  von  zwei  neuen  Fallen,"  Zeitschr.  f.  Geb.  u.  Gyn., 
Bd.  39,  p.  173)  in  189.")  and  the  following  years  showed  that  the 
tumor  originates  in  the  epithelial  cells  covering  the  chorionic  villi, 
and  is  of  a  fetal  rather  than  a  maternal  (decidual)  source,  hence; 
the  name  Chorioepithelioma,  which  has  since  been  generally 
atlopted  by  the  many  authors  reporting  cases. 

The  disease  consists  of  a  tumor  without  sharply  defined  border 
developing  in  the  mucous  membrane  of  the  body  of  the  uterus 
(very  rarely  in  the  Fallopian  tube  or  the  vagina)  and  invading  the 


MALIGNANT  CHORIOEPITHELIOMA 


281 


mucous  structure.  It  is  dark  rod  in  color,  of  soft  consistency, 
and  abundantly  supplied  with  blood.  It  has  a  tendency  to  become 
gangrenous  and  in  that  case  has  a  foul  odor. 

The  surface  is  apt  to  be  unevenly  lobulated.  On  cross  section, 
the  structure  is  seen  microscopically  to  be  made  up  of  fibrous 
septa  and  large  spaces  filled  with  extravasated,  clotted  blood,  or 
placental  tissue.  Larger  or  smaller  nodules  are  to  be  seen  in  the 
uterine  muscle,  which  becomes  often  very  thin  when  the  disease 
has  nearly  penetrated  to  the  peritoneum.  The  metastases  show 


FIG.   114. — Chorioepithelioma  of  the  Posterior  Wall  of  the  Uterus.       (Winter.) 

the  same  characteristics.  In  the  later  stages  there  are  numerous 
metastases  from  the  growth,  not  only  in  the  neighborhood  of  the 
uterus  but  in  distant  organs,  most  commonly  in  the  lungs,  and  the 
disease  proves  fatal  in  a  majority  of  cases. 

The  disease  never  occurs  except  after  pregnancy,  most  often 
after  hydatidiform  mole  and  abortion.  It  generally  occurs  only 
a  few  weeks  after  the  pregnancy,  but  may  be  delayed  several 
months. 

The  usual  chain  of  happenings  in  the  case  of  chorioepithelioma 


282      DIAGNOSIS  OF  MALIGNANT  DISEASES  OF  THE  UTERUS 

is  as  follows:  hemorrhages  occurring  after  abortion  or  the  delivery 
of  a  hydatidiform  mole,  curetting  and  the  removal  of  tissue  without 
stopping  the  bleeding,  quickly  developing  anemia,  and  signs  of 
metastases  in  the  lungs  (pain,  hemoptysis,  and  rise  of  temperature). 
It  is  plain  that  prompt  hysterectomy  is  indicated  in  order  to  save 
life.  In  exceptional  cases  the  ovum  which  has  grown  a  chorioe- 
pithelioma  is  (a)  in  the  Fallopian  tube  and  not  in  the  uterus,  and 
in  still  rarer  cases  (6)  in  the  wall  of  the  vagina. 

These  cases  are  called  Ectopic  malignant  chorioepithelioma.  In 
the  first,  (a)  the  symptoms  are  those  of  extra-uterine  pregnancy, 
arid  in  the  second,  (6)  they  are  the  same  as  in  the  uterine  variety. 
The  primary  disease  in  the  vagina  being  more  accessible  to  sight 


FIG.  115. — Metastasis  in  the   Vagina  from  Chorioepithelioma  of  the  Uterus. 

(Winter.) 

and  touch,  the  diagnosis  should  be  made  more  promptly  than 
\vhen  it  is  in  the  uterus. 

According  to  J.  Veit  ("Das  maligne  Chorioepitheliom,"  Hand- 
buck  d.  Gyn.,  ii.  Auf.,  Bd.  3,  1908)  microscopic  study  of  the  tissues 
shows  that  syncytium,  Langhans'  layer,  and  connective  tissue  of 
the  chorion,  when  all  present  in  the  same  case,  are  found  primarily 
in  the  veins  of  a  uterus  that  has  been  pregnant,  and  especially  after 
hydatidiform  mole.  If  the  epithelial  cells  of  the  chorionic  villus 
proliferate  rapidly  in  the  veins,  being  well  nourished,  the  process 
is  malignant.  The  factor  which  determines  the  malignancy  of  the 
growth  is  the  proliferating  power  of  the  epithelial  cells  and  not 
the  invasion  of  the  veins  by  the  connective  tissue  of  the  chorion. 

If  by  chance  the  proliferating  epithelial  cells  of  the  villus  get 


MALIGNANT  CHORIOEPITHELIOMA  283 

into  other  tissues  than  the  veins,  as,  for  instance,  into  the  peri- 
toneum, the  process  ceases.  A  non-malignant  form  of  the  disease 
has  been  reported,  and  at  the  present  time  authorities  are  not 
agreed  as  to  the  reason  for  the  two  .forms  or  as  to  their  differ- 
entiation before  the  specimen  reaches  the  pathological  laboratory, 
therefore  it  is  safe  to  assume  that  every  case  of  chorioepithelioma 
is  malignant  and  treat  it  accordingly. 

DIAGNOSIS 

The  diagnosis  depends  on  the  apparent  recurrence  of  a  placental 
polyp  after  abortion  or  a  hydatidiform  mole,  with  hemorrhage, 
and  a  watery,  foul  discharge.  Rapidly  developing  anemia  under 
such  conditions  is  a  suspicious  symptom,  as  the  anemia  develops 
more  rapidly  in  this  than  in  any  known  disease.  Tissue  removed 
by  the  curette  or  curette  forceps  is  submitted  to  microscopic  exam- 
ination. Better  still  the  cervix  is  dilated  until  the  canal  will  admit 
the  physician's  forefinger  and  digital  exploration  demonstrates 
the  presence  of  a  soft  tumor. 

The  tissue  of  a  chorioepithelioma  is  much  more  friable  and 
softer  than  that  of  a  placental  or  other  polypus.  The  uterus  is 
found  to  be  somewhat  enlarged  when  the  bimanual  touch  is  prac- 
ticed. In  most  cases  it  is  not  sensitive. 

In  cases  of  hydatidiform  mole  the  physician  should  keep  his 
patient  under  observation  for  several  weeks  after  the  mole  has 
been  delivered  and  should  bear  in  mind  the  possibility  of  the 
development  of  a  chorioepithelioma.  Early  removal  of  a  chorioepi- 
thelioma is  attended  by  lasting  cure. 


CHAPTER  XVII 
THE  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

Anatomy  and  age  changes,  p.  '•284. 

Anomalies,  p.  28.5.     Atrophy,  p.  28.5. 

Displacements,  p.  28(5:  Undescended  ovary,  p.  280.  Prolapse  of  the 
ovary,  p.  28(5.  Hernia  of  the  ovary,  p.  288. 

Inflammations  (Ovaritis),  p.  288:  Acute  ovaritis,  p.  288;  Diagnosis  of 
acute  overitis,  p.  288.  Chronic  ovaritis,  p.  290.  Diagnosis  of  chronic 
ovaritis,  p.  290. 

Tumors  of  the  ovary,  p.  291 :  Modes  of  development,  p.  292.  Classifica- 
tion, p.  29,'J.  Malignancy,  p.  293.  Etiology  and  symptoms,  p.  293.  Di- 
agnosis in  general,  p.  29.5.  Diagnosis  of  small  ovarian  tumors,  p.  296; 
Differential  diagnosis  of  small  ovarian  tumors,  p.  296.  Diagnosis  of  large 
ovarian  tumors,  p.  301;  Differential  diagnosis  of  large  ovarian  tumors, 
p.  30.5.  Tables,  pp.  308,  309. 

Complications  of  ovarian  tumors,  p.  315:  1.  Adhesions  and  incarceration, 
p.  31.5.  2.  Intraligamentous  development,  p.  316.  3.  Torsion  of  the  pedicle, 
p.  317.  4.  Infection  and  suppuration,  p.  318.  5.  Degenerative  processes, 
including  malignancy,  p.  318.  6.  Rupture,  p.  319.  7.  Association  with 
pregnancy,  p.  320. 

Diagnosis  of  the  different  pathological  varieties  of  ovarian  tumors,  p.  321. 

ANATOMY  AND  AGE  CHANGES 

AT  birth  the  ovary  is  an  elongated  body,  lying  parallel  with  the 
Fallopian  tube  and  resembling  in  shape  a  flattened  cucumber. 
(See  Fig.  117.)  Its  surface  is  smooth,  its  borders  may  be  crenate, 
and  it  may  have  a  longitudinal  furrow.  At  puberty  it  has  become 
transformed  into  a  smooth  olive-shaped  gland,  grayish-pink  in 
color,  li;  inche>  long  i4cm.).  :|  to  1  inch  broad  (2  to  2.5  cm.),  and 
?T  inch  thick  d  to  1  .-1  cm.)  and  weighing  about  2  drams  (6  grams). 

From  puberty  to  the  menopause  it  maintains  the  same  size  and 
shape,  but  the  smoothness  of  its  surface  is  marred  by  scars,  the 
results  of  repeated  lacerations  caused  by  the  rupture  of  the  ripe 
Clraarian  follicles.  (See  Fig.  118.) 

After  the  menopause  the  ovary  shrinks  and  becomes  wrinkled 
and  atrophic,  and  at  the  age  of  seventy  weighs  about  one  gram. 
(See  Fig.  119.) 

284 


ANOMALIES 


285 


ANOMALIES 

Congenital  absence  of  both  ovaries  is  rare  and  is  associated  with 
defective  development  of  the  uterus  and  partial  or  complete  ab- 
sence of  the  vagina.  Absence  of  one  ovary  usually  accompanies 
deficiency  of  the  corresponding  half  of  the  uterus  and  the  Fallopian 
tube,  and  absence  or  misplacement  of  the  kidney  on  the  same  side 
of  the  body.  There  is  on  record  no  reliable  description  of  a  super- 
numerary ovary ;  the  bodies  described  as  such  being  corpora  fibrosa, 
small  myomata  of  the  ovarian  ligament,  or  partially  detached  tubes 


Fimbriated 
extri 


Flmbria  octtncu. 
FIG.   116. — The  Ovary  and  Tube  Seen  from  Behind. 


(Hcnle.) 


of  the  parovarium.  Faulty  growth  of  the  ovary  is  commonly 
associated  with  the  uterine  condition  known  as  infantile  uterus, 
also  with  rudimentary  uterus. 

Atrophy  of  the  ovaries  occurs  normally  at  the  menopause.  They 
become  smaller  and  harder  and  the  oophoron  (the  egg-bearing 
zone  on  the  outside  of  the  ovary)  is  transformed  into  a  layer  of 
dense  fibrous  tissue.  Lactation  atrophy  is  a  shrinkage  in  the  size 
of  the  ovary  occurring  sometimes  in  women  who  have  nursed  their 
children  for  a  long  time.  Ovarian  atrophy  has  been  reported  in 
the  exanthemata,  nivxedenia,  marked  anemia,  and  in  diabetes. 
It  is  supposed  to  occur  in  connection  with  rapidly  acquired  obesity. 


286  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

At  all  events  young  women  who  have  suddenly  become  fat  fre- 
quently suffer  with  amenorrhea.  On  account  of  the  increase  in 
fat  in  the  abdominal  walls  it  is  not  easy  to  determine  a  decrease  in 
the  size  of  the  ovaries  in  these  patients,  but  in  certain  cases  atrophy 
has  been  definitely  made  out. 

In  1900  I  opened  the  abdomen  in  a  case  of  absolute  amenorrhea 
of  eight  months'  duration  following  steaming  of  the  uterine  cavity 
at  the  hands  of  another  practitioner.  The  woman  was  twenty- 
eight  years  old,  the  mother  of  two  children.  The  ovaries  were 
found  to  be  partially  atrophied  as  well  as  the  uterus. 

DISPLACEMENTS  OF  THE  OVARY 

(a)  Undescended  ovary,  (6)  Prolapse  of  the  ovary,  (c)  Hernia  of 
the  ovary. 

(a)  Undescended  Ovary. — The  ovaries  are  in  close  relation  with 
the  kidneys  in  the  embryo  and  they  gradually  move  downward 


FIG.  117. — Uterus,  Tubes,  and  Ovaries  of  an  Infant  One  Month  Old. 

to  the  pelvis,  at  birth  lying  on  the  psoas  magnus  muscle  in  close 
relation  with  the  internal  abdominal  ring.  They  get  to  their 
normal  situation  in  the  adult  soon  after  birth.  It  may  happen  in 
very  rare  instances  that  an  ovary  may  remain  in  the  neighborhood 
of  the  kidney  and  may  retain  its  infantile  shape.  If  it  is  the  right 
ovary  that  has  failed  to  descend  the  cecum  also  generally  remains 
high  up,  in  its  fetal  position. 

(6)  Prolapse  of  the  ovary  may  occur  when  from  repeated  preg- 


DISPLACEMENTS  OF  THE  OVARY 


287 


nancies  the  ovarian  and  broad  ligaments  have  been  stretched  and 
subsequently  not  properly  involuted,  permitting  the  ovary  to  sag 
back  into  Douglas'  cul-de-sac.  Also  when  an  ovary  is  enlarged 
for  any  reason  and  thus  gravitates  of  its  own  weight  to  the  pelvic 
floor.  Misplacements  of  the  uterus,  such  as  retroversion  and 
retroflexion,  are  commonly  associated  with  prolapse  of  the  ovaries. 
Prolapsed  ovaries  may  be  tender  to  touch,  when  we  may  assume 
that  they  are  the  seat  of  inflammation,  ovaritis.  In  this  event 


Utero- ovarian 
I  i  g  ament 


Tube 


FIG.  US. — Ovary  and  Tube  of  a  Woman  during  Sexual  Maturity; 

they  may  cause  suffering  when  pressed  on  during  the  act  of  defeca- 
tion, especially  the  left  ovary,  or  during  coitus.  The  diagnosis  is 
established  by  the  bimanual  touch.  Absence  of  the  ovary  in  its 
normal  situation  and  its  presence  at  the  base  of  the  broad  ligament 
as  determined  by  rectal  touch  are  the  diagnostic  points.  It  is 
often  difficult  to  differentiate  a  prolapsed  ovary  from  a  small 
scybalous  mass  in  the  rectum.  In  order  to  do  this  successfully, 


2SS  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

thoroughly  cleanse  the  rectum  by  enema,  and  examine  a  second 
time.  In  some  cases  it  is  well  to  use  the  proctoscope  to  be  sure 
that  the  upper  rectum  is  free.  If  the  ovary  is  tender  distinguish- 
ing it  is  easier. 

(c)  Hernia  of  the  ovary  is  comparatively  rare  in  adults  but  occurs 
not  infrequently  in  infants  under  a  year  and  a  half  old.  It  may 
occupy  a  hernial  sac  either  alone  or  accompanied  by  its  Fallopian 
tube.  Ovarian  hernia  is  more  apt  to  occur  as  an  inguinal  than 
as  a  femoral  hernia.  Congenital  hernia  of  the  ovary  is  very 
ran1,  but  it  may  occur  in  the  early  months  of  infancy  because 
the  ovaries  and  tubes  at  this  time  normally  lie  in  close  prox- 
imity to  the  abdominal  ends  of  the  inguinal  canals.  (See  Fig. 
206.)  Many  cases  reported  as  hernia  of  the  ovary  are  hydroceles 
of  the  canal  of  Xuck.  Hernia  of  the  ovary  may  occur  at  any 
age  up  to  the  seventy-third  year.  The  diagnosis  can  be  made 
definitely  only  by  operation.  It  is  difficult  to  be  sure  of  the 
absence  of  the  ovary  on  one  side.  A  hernia — preferably  an 
inguinal  hernia — having  a  tender  body  in  it,  while  at  the  same 
time  the  ovary  on  that  side  can  not  be  palpated  in  its  normal 
situation,  makes  a  probable  diagnosis. 


INFLAMMATIONS  OF  THE  OVARY 

Ovaritis  may  be  acute  or  chronic.  The  acute  form  occurs  in 
infections  following  labor  or  abortion,  gonorrhea,  typhoid  fever, 
miliary  tuberculosis,  the  acute  exanthemata,  or  mumps.  The 
ovary  is  enlarged  and  congested,  the  oophoron  or  the  paroophoron 
being  involved,  or  both.  The  tissues  are  infiltrated  with  serum, 
leucocytes  which  have  escaped  from  the  blood-vessels,  and  some- 
times with  blood.  If  there  is  a  large  collection  of  blood,  a  licma- 
tonui  of  the  ovary  is  formed.  Alwcxx  of  (lie  ovary  may  be  the  result 
of  severe  grades  of  inflammation  and  a  tumor  which  reaches  the 
size  of  an  egg  may  eventuate.  There  are  apt  to  be  adhesions  to 
the  surrounding  structures,  such  as  the  Fallopian  tubes  and  in- 
testines. The  abscess  may  rupture  into  the  intestine,  bladder,  or 
vagina.  Tt  has  been  known  in  rare  cases  to  break  into  the  general 
peritoneal  cavity,  causing  fatal  peritonitis. 

Diagnosis  of  Acute  Ovaritis. — Pelvic  pain  aggravated  by  move- 


INFLAMMATIONS  OF  THE  OVARY 


289 


mcnt  of  the  body  or  by  defecation,  and  tenderness  on  pressure  in 
the  ovarian  regions,  are  characteristic  of  a  mild  attack  of  ovaritis. 
Chills  and  marked  elevation  of  the  body  temperature  are  to  be 
expected  if  suppuration  occurs.  If  there  is  peritonitis  of  any 
extent  there  will  be  rigidity  of  the  abdomen  and  a  rapid  and  small 
pulse  and  increased  pain.  If  it  is  possible  to  palpate  the  ovary 
it  will  be  found  enlarged  and  exquisitely  tender.  Commonly  the 
rigidity  of  the  abdominal  walls  prevents  exact  differentiation  of 
the  structures  involved.  An  abscess  is  usually  fixed  in  a  mass  of 
exudate.  Fluctuation  may  be  made  out  by  rectal  palpation,  but 


Atrophied- 


FIG.   119. — Senile  Ovary  and  Tube. 

often  the  wall  of  the  abscess  is  so  thick  that  this  is  impossible. 
In  the  case  of  acute  ovaritis  it  is  impossible  to  distinguish  exactly 
between  ovaritis  and  salpingitis.  If  the  disease  is  right-sided  we 
must,  if  possible,  eliminate  appendicitis.  The  history  of  the  onset 
is  the  important  point  in  distinguishing  the  two.  Acute  pelvic 
inflammation  is  generally  preceded  by  a  vaginal  discharge  or  other 
uterine  symptoms  such  as  dysmenorrhea,  whereas  in  appendicitis 
there  is  a  history  of  digestive  disturbances,  such  as  diarrhea  alter- 
nating with  constipation,  or  of  previous  attacks  of  pain  in  the 
right  lower  abdomen.  The  pain  of  pelvic  disease  is  dull  and  steady 
and  is  situated  doc'})  in  the  pelvis,  pressure  over  Poupart's  ligament 
19 


290 


DIAGNOSIS  OF  DISEASES   OF  THE  OVARIES 


occasioning  great  suffering.  The  pain  of  appendicitis  is  sharp 
and  colicky  and  is  higher  in  the  abdomen  and  is  more  diffused. 

If  the  appendix  happens  to  be  in  the  pelvis  or  if  there  is  much 
peritonitis  it  is  impossible  to  distinguish  the  two  affections. 

Chronic  ovaritis  may  follow  an  acute  ovaritis  or  it  may  originate 
in  an  infection  of  the  uterus,  especially  in  gonorrhea.  It  is  also 
found  in  the  presence  .of  fibromyomata  and  large  ovarian  tumors 
of  the  opposite  side,  although  the  disease  is  generally  bilateral. 

The  oophoron  is  usually  affected,  the  Graafian  follicles  often  be- 
coming enlarged  and  causing  atrophy  of  the  stroma  because  of  their 
size.  Such  a  condition  is  called  small  cystic  degeneration.  In  certain 
cases  the  entire  cortical  region  of  the  ovary  (oophoron)  is  trans- 
formed into  little  cysts  containing  a  clear  fluid,  the  ovum  having  dis- 


oopKo*- 


FIG.   120. — Diagram  Showing    the   Cyst   and    Tumor   Regions    of   the    Ovary. 

(After  Bland-Sutton.) 

appeared.  Xow  and  then  a  few  normal  follicles  may  be  found.  In 
some  cases  of  chronic  ovaritis,  the  stroma  and  not  the  follicles  is  in- 
volved. In  the  late  stages  of  this  disease  the  ovary  is  found  small  and 
scirrhotic  with  a  puckered,  uneven  surface,  as  from  many  scars. 

Diagnosis  of  Chronic  Ovaritis. — There  is  nothing  pathognomonic 
in  the  symptoms  of  this  disease.  There  is  apt  to  be  pain  in  the 
ovarian  regions,  and  scanty  menstruation  if  the  ovarian  stroma 
has  been  destroyed,  also  dysmenorrhea.  The  ovaries  may  be 
tender  to  the  touch;  often  they  are  not.  The  bimanual  touch  may 
determine  follicular  enlargement  or  a  nodular  feel.  In  only  ex- 
ceptional cases  when  all  the  factors  are  favorable,  more  especially 
at  an  examination  under  an  anesthetic,  can  a  small  cirrhotic  ovary 
be  diagnosed. 


OVARIAN  TUMORS  291 


OVARIAN  TUMORS 

We  have  considered  already  certain  states  of  the  ovary  that 
strictly  may  be  classed  as  tumors,  for  instance,  "small  cystic  de- 
generation" and  inflammatory  conditions  with  enlargement. 

Let  us  now  take  up  ovarian  tumors  proper,  counting  as  tumors 
all  enlargements  of  the  ovary  greater  in  size  than  a  hen's  egg,  using 
Pfannenstiel's  classification  based  on  the  origin  of  the  tumor. 
(Veit's  "Handbuch,"  J.  Pfannenstiel,  "Die  Erkrankungen  des 
Ovarium.") 

A.  NON-PROLIFERATING  CYSTS. 

(Follicular  cysts;   Cysts  of  the  corpus  luteum.) 

B.  NEW  FORMATIONS. 

I.  Parenchymatogenous  Tumors. 

(Tumors  arising    from    germinal   or   follicular  epithelium,, 
or  from  the  ovum.) 

1.  Epithelial  New  Formations, 
(a)  Cystoma  serosum  simplex. 

(Simple  cyst.) 

r  Pseudomucinosum. 

(Multilocular  cysts.) 
(o)  Cyst  adenoma         0 

i  Serosum. 

(Papillary  cysts.) 
(c)  Carcinoma. 

2.  Embryomata. 

(Tumors  springing  from  the  ovum.) 
(o)  Dermoid  cysts. 
(6)  Teratomata. 

II.  Stromatogenous  Tumors. 

(Tumors  arising  from  the  connective  tissue.) 

1.  Fibroma. 

2.  Sarcoma. 

3.  Peri-  and  Endothelioma. 
(\  MIXKD  TUMORS. 

(Various  combinations  of  the  tumor  processes  enumerated.) 

Fig.  120  shows  diagrammatically  the  different  portions  of  the 
ovary  affected  by  neoplasms. 


292 


DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 


MODES  OF  DKVKLOPMKXT  OF  OVARIAN  TUMORS 

The  accompanying  diagrams  indicate  the  method  of  develop- 
ment of  the  pedicle  of  a  tumor  and  the  arrangement  of  the  peri- 
toneum in  the  case  of  the  normal  ovary,  a  free  ovarian  cyst,  an 
intraligamentous  cyst,  and  an  adherent  ovarian  cyst.  It  is  plain 
that  the  broad  ligament,  the  Fallopian  tube,  the  round  ligament, 


ftdicle. 


Tdllopian 
'tube 


Fios.   121-124. — Four    Diagrams   Showing   the   Method    of   Formation    of   the 
Pedicle  in  the  Different  Sorts  of  Ovarian  Tumors. 

and  the  ovarian  ligament  are  included  in  varying  degrees  in  the 
pedicle  of  a  large  non-adherent  ovarian  tumor.  Commonly  the 
Fallopian  tube  is  much  elongated  and  spread  over  the  surface  of 
the  tumor,  the  round  ligament  comes  on  to  the  anterior  face  of  the 
tumor,  and  the  ovarian  ligament  is  much  enlarged  and  lengthened. 
In  the  case  of  tumors  developing  between  the  layers  of  the  broad 
ligament,  or  of  adherent  ovarian  tumors,  the  conditions  are  as 
shown  in  the  diagram.  A  parovarian  cyst  may  lie  free  in  the 


OVARIAN  TUMORS  293 

pelvis  attached  only  by  a  pedicle  formed  from  the  broad  ligament, 
and  it  is  not  unusual  to  find  such  a  cyst  as  a  complication  of  a  small 
ovarian  tumor. 

CLASSIFICATION 

Ovarian  tumors  have  been  generally  classified  as  solid  or  cystic, 
and  benign  or  malignant.  As  will  be  seen  from  the  classification 
of  Pfannenstiel,  such  a  division  is  arbitrary  and  many  of  the  tumors 
are  both  solid  and  cystic,  and  also  benign  and  malignant.  This  is 
shown  by  careful  microscopic  examination  in  the  pathological 
laboratory  where  a  unilocular  cyst  will  be  found  often  to  have 
small  cysts  in  its  walls,  or  trabeculse  in  the  cyst  walls,  denoting 
former  subdivisions.  Some  of  the  multilocular  cysts  show  papillary 
masses  in  certain  regions,  while  in  other  places  small  dermoid  cysts 
may  be  discovered,  and  even  areas  of  cancerous  degeneration. 


MALIGNANCY 

A  benign  tumor  is  one  which  does  not  tend  to  recur  when  extir- 
pated, as  well  as  one  which  does  not  implant  itself  elsewhere  or 
invade  the  tissues. 

A  malignant  tumor  signifies  a  growth  which  tends  to  destroy  life 
by  invasion  of  the  surrounding  tissues  as  well  as  one  which  dis- 
tributes its  elements  by  metastasis  to  other  parts  of  the  body. 

In  a  general  way  one  may  say  that  the  cystadenomata  (multi- 
locular cysts),  the  parovarian  cysts,  the  fibroids  of  the  ovary,  and 
the  dermoid  cysts  are  benign;  the  carcinomata  and  sarcomata  are 
malignant,  and  the  papillary  tumors  are  on  the  border  land.  That 
is  to  say,  the  papillary  cystadenomata  tend  to  implant  their  ele- 
ments on  the  surrounding  structures,  there  to  grow,  but  they  do 
not  invade  the  underlying  structures  as  do  the  carcinomata  and 
sarcomata. 

ETIOLOGY  AND  SYMPTOMS 

Ovarian  tumors  are  found  most  often  during  the  time  of  sexual 
activity  in  the  life  of  women,  but  may  occur  at  any  age.  Chiene 


294 


DIAGNOSIS   OF  DISEASES  OF  THE  OVARIES 


and  V.  B.  Lund  have  each  removed  an  ovarian  cyst  from  a  child 
three  months  old,  and  Thornton  operated  successfully  on  a  woman 
ninety-four  years  of  age. 

It  is  supposed  that  the  germ  of  most  tumors  exists  from  fetal 
life  and  that  when  the  proper  stimulant  conies  the  tumor  develops. 


Fn;.   12.3. — Very   Largo   Ovarian   Cyst    with   Characteristic   Emaciation   about 
the  Chest  and  "  Facies  Ovarina."     (Kelly.) 

The  controlling  factors  are  unknown.  The  symptoms  consist, 
during  the  early  stages  of  the  growth  of  an  ovarian  tumor,  in  the 
usual  syndromata  of  uterine  diwuxc,  and  may  be  of  little  moment 
to  the  patient,  so  that  her  attention  is  not  directed  to  the  pelvis. 
Thev  are  menstrual  disturbances, — such  as  dvsmenorrhea,  menor- 


OVARIAN  TUMORS  295 

rhagia,  or  scanty  menstruation, — a  sense  of  weight  in  the  pelvis,  or, 
if  there  is  peritonitis,  pain.  When  the  tumor  attains  a  considerable 
size,  so  that  it  fills  the  pelvis  or  rises  out  of  it  into  the  abdomen, 
there  are  pressure  symptoms.  These  are  vesical  or  rectal  tenes- 
mus,  frequent  micturition,  and  constipation;  in  the  case  of  large 
tumors,  edema  of  the  vulva  and  of  the  lower  extremities  caused 
by  pressure  on  the  iliac  veins;  also  hemorrhoids.  In  rare  cases 
there  have  been  noted  albuminuria  and  suppression  of  urine  from 
hydronephrosis  caused  by  pressure  on  the  ureters.  Other  symp- 
toms are  jaundice  from  occlusion  of  the  bile  ducts,  ascites  from 
pressure  obstruction  to  the  portal  system,  dilated  veins  in  the 
skin  of  the  abdomen,  the  occurrence  of  the  white  lines  in  the  skin 
known  as  linese  albicantes,  occasional  umbilical  hernia,  and  de- 
rangements of  digestion  and  dyspnea. 

Pain  in  the  abdomen  is  a  symptom  of  adhesions,  as  a  rule,  and  great 
care  should  be  observed  in  taking  the  anamnesis  to  get  the  exact  sit- 
uation, character,  and  duration  of  the  pain.  Pain  is  caused  also  by 
traction  or  torsion  of  the  pedicle  and  by  secondary  changes  in  the 
contents  of  the  cyst  involving  adhesions  to  the  sensitive  parietal 
peritoneum. 

The  fades  ovarina  is  a  peculiar  facial  expression  that  is  pathog- 
nomonic  of  the  late  stage  of  large  ovarian  tumors.  It  consists 
of  an  anxious,  careworn  look;  the  face  is  pale  and  shriveled,  there 
being  wrinkles  in  the  cheeks,  and  it  looks  longer;  the  nostrils  are 
wide  and  the  lips  thin,  the  space  between  the  eyelids  and  the  bony 
margin  of  the  orbits  is  sunken.  The  face  does  not  have  that 
yellowish  hue  characteristic  of  the  late  stages  of  cancer,  nor  yet 
the  full  appearance  of  the  face  of  the  pregnant  woman. 

There  is  also  to  be  noted  in  large  ovarian  tumors  a  loss  of  flesh 
over  the  chest  and  shoulders,  probably  of  a  piece  with  the  atrophy 
of  the  face  just  described. 


DIAGNOSIS  ix  GENERAL 

In  considering  the  diagnosis  of  ovarian  tumors  it  is  convenient 
to  divide  them  into  *mu.H  tumor*,  those  that  lie  wholly  within  the 
pelvic  cavity  proper,  and  lo.rtjc  tumor*,  those  that  lie  for  the  most 
part  in  the  abdominal  cavity.  We  will  discuss  the  diagnosis  and 


296  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

the  differential  diagnosis  of  each,  then  take  up  the  complications 
of  ovarian  tumors,  and  finally  say  something  of  the  diagnosis  of 
the  different  pathological  varieties  of  tumors,  as  far  as  they  can  be 
distinguished  without  operation. 

The  important  factor  in  the  diagnosis  of  all  ovarian  tumors 
is  to  determine  the  relation  of  the  tumor  to  the  uterus. 

If  it  can  be  shown  that  moving  the  tumor  moves  the  uterus,  or, 
conversely,  that  changing  the  position  of  the  uterus  moves  the 
tumor,  there  is  a  probability  that  the  tumor  is  ovarian.  On  ac- 
count of  adhesions  and  intraligamentous  development,  all  ovarian 
tumors  are  not  movable.  The  tumors  of  medium  size,  those  that 
have  risen  out  of  the  pelvis  but  have  not  yet  distended  the  ab- 
dominal walls  to  excessive  degree,  are  easiest  to  palpate  with 
reference  to  their  connection  with  the  uterus.  To  perform  the 
palpation  to  the  best  advantage,  use  is  made  of  the  bimanual 
vagino-abdominal  touch. 

With  the  forefinger  against  the  cervix,  push  the  tumor  in  the  abdo- 
men or  pelvis  to  one  side  with  a  quick  movement  of  the  hand  on  the 
abdomen.  At  the  same  moment  the  cervix  will  be  felt  to  move  be- 
cause of  the  pull  on  the  pedicle  of  the  tumor.  Sometimes,  but  not 
often,  a  quick  push  on  the  uterus  by  the  finger  in  the  vagina  will  be 
transmitted  to  the  tumor,  as  detected  by  the  hand  on  the  abdomen. 

To  palpate  the  pedicle  the  cervix  is  grasped  by  a  double  tenacu- 
lum  held  by  an  assistant  while  the  physician  practices  the  bimanual 
recto-abdominal  touch,  with  t\vo  fingers  in  the  rectum.  (See  Fig. 
126,  page  301.) 

In  this  way  it  is  possible  sometimes  to  get  a  good  idea  of  the 
situation,  size,  and  length  of  the  pedicle  of  a  tumor.  As  pointed 
out  by  John  A.  Sampson  ("  Surgery,  Gynecology  and  Obstetrics/'' 
1907,  Vol.  IV.,  p.  685),  traction  on  the  pedicle  of  an  ovarian  tumor 
causes  pain.  Also  twisting  of  the  pedicle,  as  determined  by  opera- 
tions performed  on  patients  by  the  aid  of  local  anesthesia,  causes 
pain  which  is  referred  to  the  pelvis  on  the  side  on  which  the  pedicle 
is  situated. 

DIAGNOSIS  OF  SMALL  OVARIAN  TUMORS 

Those  tumors,  which  lie  entirely  within  the  cavity  of  the  true 
pelvis,  are  diagnosed  by  the  bimanual  touch,  both  vagino-abdominal 


SMALL  OVARIAN  TUMORS      •  297 

and  recto-abdominal.  In  the  case  of  the  small  tumor  it  is  difficult 
to  make  out  the  characteristics  of  the  pedicle.  One  determines 
this  in  some  cases  as  described  above.  We  try  to  ascertain  the 
position,  size,  form,  and  density  of  any  given  pelvic  tumor;  then 
its  relation  to  the  uterus.  If  the  tumor  is  small  there  is  a  likelihood 
that  the  uterus  can  be  placed  and  its  size  and  shape  defined  by 
touch.  In  the  larger  tumors,  those  filling  the  pelvis,  such  palpa- 
tion is  difficult  or  impossible.  In  this  event  the  sound  must  be 
passed  to  determine  the  location  and  relative  size  of  the  uterus. 
As  a  rule,  ovarian  tumors  are  round.  This  is  always  the  case  with 
the  cysts,  the  solid  tumors  being  generally,  but  not  invariably, 
round.  A  fluctuating  consistency  can  be  made  out  in  most  cases 
of  cysts.  A  small-sized  ovarian  cyst  is  to  be  looked  for  in  the 
situation  of  the  ovary,  and  is  movable  (rarely  adherent) ;  an  intra- 
ligamentous  cyst  lies  to  one  side  arid  behind  the  uterus,  and  is 
immovable.  A  cyst  may  lie  in  front  of  the  uterus,  rarely,  and,  of 

course,  there  may  be  two  ovarian  tumors,  one  on  each  side. 

> 

Differential  Diagnosis  of  Small  Ovarian  Tumors 

We  must  rule  out. : 

1.  Ovaritis. 

2.  Subperitoneal  fibroid. 

3.  Parovarian  cyst. 

4.  Hydrosalpinx,  homatosalpinx,  and  pyosalpinx. 

5.  Encapsulated  peritonitis,  or  inflammatory  exudate. 

6.  Echinococcus  cyst. 

7.  Extra-uterine  pregnancy. 

8.  Early  normal  pregnancy,  or  cornual  pregnancy. 

9.  Distended  urinary  bladder. 

1.  Ovaritis. — Tumors  of  the  chronic  form  of  ovaritis  are  seldom 

larger  than  a  pigeon's  egg,  but  the  acute  form  resulting  in  abscess 
may  bo  of  considerable  size.  Here  there  is  fever,  and  the  tumor  is 
of  recent  occurrence,  an  acute  affair.  The  tumor  is  tender,  and 
there  is  pelvic  peritonitis  in  varying  degress  of  intensity  as  evi- 
denced by  rigidity  of  the  abdominal  walls.  Also  there  is  generally 
a  history  of  infection. 

2.  Subperitoneal  Fibroid.— The  differentiation  in  this  case  is  often 


298  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

a  difficult  matter  and  depends  entirely  on  the  findings  from  palpa- 
tion. The  consistency  of  an  ovarian  cyst  is  softer  than  that  of  a 
suhserous  fibroid.  As  a  rule,  the  fibroid  is  more  intimately  allied 
with  the  uterus,  and  in  many  cases  the  pedicle  is  short  and  thick 
or  the  growth  is  sessile.  It  helps  in  the  diagnosis  if  other  fibroid 
nodules  can  be  distinguished  in  the  substance  of  the  uterus,  for 
fibroids  are  apt  to  be  multiple.  The  coexistence  of  ovarian  cyst 
and  fibroid  is  not  an  uncommon  occurrence. 

In  the  case  of  an  interstitial  fibroid  the  uterus  should  be  enlarged 
and  menorrhagia  is  apt  to  be  a  symptom;  the  passage  of  the  sound 
will  show  an  increased  depth  of  the  uterine  cavity. 

If,  by  any  chance,  both  normal-sized  ovaries  can  be  palpated,  the 
tumor  is  a  uterine  fibroid. 

3.  Parovarian  Cyst. — Parovarian   cysts  are  generally   relatively 
small  in  size,  therefore  they  are  put  here.     They  may  be  large, 
however.     The  cyst  arises  from  the  epoophoron,  is  generally  uni- 
locular,  and  has  a  thin  wall,  with  clear  serous  contents.     It  is  situ- 
ated between  the  tube  and  ovary  and  is  intra-ligamentous  in  growth; 
therefore,  when  the  cyst    has  developed  the  tube  is  on  its  upper 
surface  and  the  ovary  below  it.     In  extremely  rare  cases  the  ovary 
may  be  palpated  by  the  finger  in  the  Vagina  on  the  under  surface 
of  the  cyst.      As  a  rule,   the  differential   diagnosis  can   not   be 
made. 

4.  Hydrosalpinx,  Hematosalpinx,  and   Pyosalpinx. — The  accumu- 
lation of  serous  fluid,  blood,  or  pus  in  the  Fallopian  tube  gives  it  a 
more   or  less   characteristic   shape.     This   is   a   strong   diagnostic 
point.     A  pyriform  swelling  with  its  small  end  at  the  uterine  horn 
is  indicative  of  a  dilated  tube.     In  the  case  of  hydrosalpinx  and 
hematosalpinx  there   is,   as   a  rule,   no   complicating   peritonitis, 
therefore  the  diagnosis  is  easier  than  in  the  case  of  pyosalpinx, 
which  is  apt  to  be  surrounded  by  exudatc.     Hydrosalpinx  and 
hematosalpinx  never  reach  the  great  size  of  exceptional  cases  of 
pyosalpinx.     It  is  unusual  for  any  variety  to  be  more  than  an  inch 
and  a  half  (3  cm.)  in  diameter  or  five  inches  (12  cm.)  long.     The 
hydrosalpinx  has  a  thin  wall,  and  fluctuation  can  be  determined 
without   much  difficulty:   pyosalpinx  has  thick   walls  because  of 
inflammatory  action  in  the  tube  and  also  in  the  peritoneum  sur- 
rounding it,  and  it  is  not  easy  to  make  out  fluctuation. 

5.  Encapsulated  Peritonitis. — If  a  quantity  of  serous  or  purulent 


SMALL  OVARIAN  TUMORS  299 

cxudatc  in  the  case  of  pelvic  peritonitis,  or  a  quantity  of  ascitic 
fluid  becomes  encapsulated  by  peritoneal  adhesions,  the  condition 
may  be  mistaken  for  a  cystic  tumor  of  the  ovary.  Such  a  condi- 
tion is  relatively  rare,  however.  Generally  there  is  evidence  of 
tuberculosis  or  carcinosis  or  actinomycosis  of  the  peritoneum  and 
the  manifestations  of  the  disease  in  the  general  cavity  of  the  peri- 
toneum overshadow  those  in  the  pelvic  cavity.  Such  circum- 
scribed collections  of  fluid  in  the  pelvic  cavity  have  an  irregular 
shape  and  are  not  often  round.  Also  fluid  is  apt  to  be  present  in 
other  portions  of  the  peritoneum. 

6.  Echinococcus  Cyst. — Echinococcus  cyst  of  the  pelvis  is  rare. 
Primary  echinococcus  disease  of   the  ovary  is    unknown,  but  it 
occurs  in  the  following  situations  in  the  pelvis:     (a)  the  uterus, 
(6)  the  mesometrium,  (c)  the  pelvic  bones,  (d)  the  omentum,  and 
(e)  the   Fallopian  tubes.     Also  downward  extension  of  hydatid 
disease  of  the  liver  may  reach  the  pelvis.     Echinococcus  cyst  is 
round  and  fluctuates;  but,  as  a  rule,  is  more  distended  and  has 
thicker  walls  than  an  ovarian  tumor,  and  it  is  generally  densely 
adherent  to  the  surrounding  structures.     Bland-Sutton  ("Surgical 
Diseases  of  the  Ovaries  and  Fallopian  Tubes,"  1891,  p.  183)  says 
that  a  "peculiar  sign — hyatitl  fremitus — can  sometimes  be  obtained 
by  placing  the  palm  of  the  left  hand  upon  the  tumor  and  sharply 
percussing  with  the  finger  of  the  right.     It  is  a  peculiar  tremor  or 
thrill,  only  felt  over  a  hyatid  cyst."     In  this  country  hydatid  dis- 
ease is  very  rare. 

7.  Extra-Uterine  Pregnancy. — This  gives  a  history  of  pregnancy. 
Before  rupture  there  is  a  boggy  fluctuating  or  elastic  tumor  at  the 
side  and  back  of  the  uterus.     It  is  the  shape  of  a  distended  tube. 
Look  for  purple  discoloration  of  the  vagina  with  increased  dis- 
charge, and  for  changes  in  the  breasts  together  with  uterine  en- 
largement and  softening  of  the  cervix,  also  pain  on  moving  the 
cervix.     About  the  time  of  mtra-abdominal  rupture  of  the  preg- 
nant sac  the  endometrium  casts  off  a  modified  decidua  of  pregnancy 
with  more  or  less  uterine  hemorrhage.     At  the  time  of  rupture  the 
symptoms  are  those  of  intra-abdominal  hemorrhage  and  are  urgent. 
There  is  a  fulness  in  the  cul-de-sac  with  abdominal  distention, 
rapid,  feeble  pulse,  severe  pain  in  the  abdomen,  and  collapse.     If 
in  a  chronic  cast1  a  hematocele  has  formed,  there  is  a  boggy  mass 
in  the  cul-de-sac,  generally  filling  the  pelvis,  the  uterus  being  in 


:300  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

front.     There  may  be  a  history  of  repeated  attacks  of  pain  recurring 
at  irregular  periods. 

8.  Normal  Pregnancy. — Early  normal  pregnancy,  particularly  if 
the  pregnancy  begins  in  one  horn  of  the  uterus,  may  be  mistaken 
for  ovarian  cyst.     It  should  not  be  forgotten  that  the  two  condi- 
tions frequently  coexist.     First,  the  history  indicates  pregnancy. 
Inquire  for  amenorrhea  and  morning  nausea  and  whether  there 
has  been  coitus.     The  uterus  in  pregnancy  is  anteflexcd,  there  is 
bulging  of  the  lower  uterine  segment  anteriorly,  the  uterine  tissues 
have  a  peculiar  elastic   feel  and  are  compressible  by  bimanual 
touch  (Hegar's  sign;  see  Fig.  178).     The  cervix  is  soft  and  there 
are  increased  vaginal  discharge  and  purplish  discoloration  of  the 
anterior  vaginal  wall  and  introitus  vaginae,  noticeable  as  early  as 
the  sixth  week  in  some  instances,  though  usually  not  quite  so  early. 
The  breasts  are  full,  the  veins  showing  in  the  skin;  the  areolse  are 
pigmented  and  show  enlargement  of  the  follicles.     There  may  be 
secretion  from  the  breasts.     In  the  case  of  pregnancy  in  one  horn 
of  a  bifurcated  uterus  the  history  of  pregnancy  is  to  be  obtained. 
There  is  no  bulging  of  the  lower  uterine  segment,  but  the  other 
signs  of  pregnancy  are  the  same.     There  is  no  fluctuation  in  the 
pregnant  uterus  until  the  stage  of  "ballottement."     This  is  not 
available  as  a  diagnostic  sign  until  the  twenty-first  week  of  preg- 
nancy when  there  is  sufficient  fluid  in  the  amnion  and  the  fetus  is 
heavy  enough  to  give  the  characteristic  feeling  as  the  fetus  bobs 
about  when  jostled  by  the  sudden  impact  of  the  examiner's  finger 
in  the  vagina. 

9.  A  Distended  Urinary  Bladder. — If  the  rules  for  the  preparation 
of  the  patient  for  an  examination  have  been  observed  (see  Chapter 
IV.,  page  23)   it  will  have  been  learned  that  the  patient  has  been 
unable  to  urinate,  and  therefore  a  catheter  has  been  passed.     It 
sometimes  happens  that  a  patient  is  unable  to  speak  the  language 
or  is  unconscious,  and  the  question  of  ovarian  tumor  arises.     It 
is  safe  to  pass  the  catheter  if  there  is  the  slightest  doubt  that  the 
bladder  is  empty.     Upon  palpation  the  full  bladder  is  not  so  mov- 
able as  an  ovarian  cyst,  as  a  rule,  and  the  uterus  is  retroverted 
under  the  bladder.     Dribbling  of  urine  is  apt  to  be  a  symptom  of 
an  overfilled  bladder. 


LARGE  OVARIAN  TUMORS 


^ 

LLEGE  OF 


DIAGNOSIS  OF  LARGE  OVARIAN  TUMORS 

Large  ovarian  tumors  are  those  which  are  too  large  to  be  con- 
tained in  the  true  pelvis  and  are  of  abdominal  development.  They 
fill  the  abdomen  to  a  greater  or  less  degree  and  lie  on  the  false 
pelvis.  The  diagnosis  depends  in  great  measure  on  the  determina- 


FIG.  126. — Hegar's  Method  of  Determining  the  Relation  of  Tumors  to  the  Uterus. 

tion  of  the  connection  of  the  tumor  by  pedicle  with  one  or  the 
other  side  of  the  fundus  uteri.  If  the  tumor  is  very  large  such 
determination  is  difficult  of  accomplishment.  If  the  tumor  is 
smaller,  so  that  there  is  space  to  move  it  within  the  abdominal 
walls,  moving  the  tumor  will  be  felt  by  the  finger  in  the  vagina  to 
pull  the  uterus  at  the  same  time.  By  rectal  palpation,  after  trac- 
tion on  the  cervix  has  been  made  by  a  double  tenaculum,  the  physi- 


302 


DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 


cian  may  Ixi  aNo  to  distinguish  the  situation  and  characteristics 
of  the  pedicle.     (See  Fig.  ll>(>,  page  301.) 

Inspection. — Inspection  of  the  abdomen  of  a  woman  having  a 
moderately  large  ovarian  tumor  will  show  the  enlargement  most 
pronounced  on  the  side;  from  which  the  tumor  has  sprung.  This 
is  not  the  case  with  very  large  tumors.  As  a  rule  the  enlargement 
is  in  the  lower  portion  of  the  abdomen.  B.  C.  Hirst  (" Diseases  of 
Women,"  Second  Edition,  p.  .139)  has  seen  three  cases  in  which 
an  ovarian  tumor  was  in  the  upper  abdomen — twice  due  to  tight 
lacing  and  once  to  the  fact  that  the  tumor  was  elevated  in  preg- 


Dull 


Tympan 


Tympanitic 


FIG.   127. — Diagram  of  a  Cross  Section  of  the  Body  in  the  Case  of  an  Ovarian 

Tumor. 


nancy,  became  adherent  to  the  liver,  and  did  not  descend  with 
involution  of  the  uterus. 

When  the  tumor  has  been  long  existent  we  expect  to  find  the 
facie*  ovarina  and  loss  of  flesh  about  the  chest  and  shoulders. 
Unless  ascites  is  present  or  the  tumor  is  excessively  large,  there  is 
no  bulging  in  the  flanks. 

Palpation. — Palpation  usually  shows  a  fluctuating  tumor,  more 
distinctly  felt  on  the  affected  side.  The  elasticity  will  depend  on 
the  sort  of  tumor  present,  and  on  the  tenseness  of  the  cyst.  If 
the  tumor  is  very  tense  it  may  feel  like  a  solid  mass.  It  is  rare 
for  solid  (issues  to  predominate  in  ovarian  tumors.  Xodules  may 
be  felt  and  loculi  of  a  niultllocular  tumor  if  the  abdominal  walls 
are  thin.  If  the  walls  are  verv  tense  or  thick  it  is  necessarv  often  to 


LARGE  OVARIAN  TUMORS 


303 


administer  an  anesthetic  before  a  satisfactory  examination  can 
be  made.  The  mobility  of  the  tumor  depends  on  the  length  of  its 
pedicle,  the  relation  between  the  size  of  the  tumor  and  the  size  of 
its  abdomen,  and  the  presence  of  adhesions. 

By  means  of  the  bimanual  vagino-abdominal  or  recto-abdominal 
touch  it  may  be  possible  to  determine  that  the  uterus  is  not  en- 
larged and  is  separate  from  the  tumor,  and  the  pedicle  may  be 
mapped  out  by  traction  on  the  uterus.  Also  the  connection  of  the 
tumor  may  be  made  plain  by  moving  the  tumor  suddenly,  the  im- 


FIG.  128. — Large  Parovarian  Cyst  Seen  in  Profile.     (Kelly.) 

pulse  transmitted  to  the  uterus  being  appreciated  by  the  finger  in 
the  vagina  or  rectum. 

Percussion. — With  the  patient  in  the  dorsal  position  the  tumor 
occupies  the  lower  anterior  portion  of  the  abdomen.  The  intes- 
tines, held  by  their  mesentery,  are  nearer  the  diaphragm  and 
at  the  sides  of  the  tumor;  therefore  tympanitic  resonance  is  found 
in  the  epigastrium,  flatness  over  the  tumor,  and  dullness  or  modi- 
fied resonance  in  the  Hanks.  These  areas  of  resonance,  flatness,  and 
dullness  do  not  change  with  change  in  the  position  of  the  patient, 
as  regards  the  side  position  or  the  standing  position.  If  the  tumor 
contains  fluid,  a  percuxxion  icare  may  be  elicited  by  placing  a  hand 
on  each  side  of  the  abdomen  and  then  tapping  with  the  finger  of 


304 


DIAGNOSIS   OF  DISEASES   OF  THE  OVARIES 


one  hand.  A  vibration  will  be  felt  by  the  opposite  hand.  If 
the  abdominal  walls  are  very  fat  the  fat  may  transmit  a  wave  by 
itself;  therefore,  to  eliminate;  this  fat  wave  have  an  assistant  place 
a  hand  with  the  ulnar  edge  down  along  the  middle  line  of  the  ab- 


FK;.   129. — The    Viirious  Abdominal   Organs  from  Which   Tumors   May    Arise. 

(Kelly.) 

domen  and  press  firmly.     If  the  fluid  in  the  cyst  is  thick,  as  in 
dermoids,  the  percussion  wave  may  be  slight  or  absent. 

Measurements. — Measurements  of  the  abdomen  show  an  increase 
or  decrease  in  the  size  of  a  tumor  from  time  to  time.     Thev  are 


LARGE  OVARIAN  TUMORS  305 

made  with  a  tape  measure  at  some  definite  point,  as  about  the 
body  at  the  umbilicus,  or  at  the  anterior  superior  spines  of  the  ilia. 
Other  measurements  are,  the  distance  from  the  tip  of  the  ensi- 
form  cartilage  to  the  upper  margin  of  the  symphysis  pubis  and 
a  measurement  made  with  the  pelvimeter,  the  patient  being  in  a 
standing  position,  from  the  upper  apex  of  Michaelis'  rhomboid  area 
on  the  back  over  the  sacrum,  to  the  most  prominent  point  of  the 
tumor.  These  measurements  must  be  taken  each  time  with  the 
patient  in  exactly  the  same  position,  whether  standing  or  on 
the  side  and  always  with  the  bowels  free. 

Aspiration  or  tapping  an  ovarian  tumor  is  never  justifiable  as  a 
means  of  diagnosis,  and  exploratory  incision  is  to  be  practiced  only 
when  it  is  impossible  to  make  a  diagnosis  and  all  the  preparations 
have  been  made  for  a  complete  operation. 


Differential  Diagnosis  of  Large  Ovarian  Tumors 

We  must  rule  out: 

1.  Pregnancy. 

2.  Ascites. 

3.  Fibroids. 

4.  Accumulations  of  gas  or  fecal  matter  in  the  intestines. 

5.  Fat  or  tumors  in  the  abdominal  walls,  including  "Phantom 

Tumor." 

6.  Cyst  of  the  pancreas. 

7.  Tumors  of  the  spleen,  liver,  and  kidneys. 

8.  Cyst  of  the  omentum. 

9.  Echinococcus  cysts. 

10.  Dilated  stomach. 

11.  Distended  urinary  bladder. 

i.  Pregnancy. — It  should  be  assumed,  until  the  contrary  has 
been  proven,  that  every  abdominal  enlargement  in  a  woman  is 
due  to  pregnancy.  In  this  way  many  embarrassing  mistakes  will 
be  avoided.  The  diagnosis  of  early  pregnancy  has  been  considered 
in  treating  of  the  small  ovarian  tumors.  Advanced  pregnancy  is 
to  be  excluded  by  the  history.  It  is  possible  to  have  amenorrhea 
in  ovarian  tumor,  especially  whore  both  ovaries  have  become  dis- 
20 


300 


DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 


organized  by  the  disease  affecting  them,  but  it  is  unusual.  Morn- 
ing nausea  and  vomiting  during  the  early  months,  or  salivation 
and  heartburn  and  swelling  of  the  breasts,  are  characteristic  of  preg- 
nancy. Sometimes  these;  symptoms  have  occurred  at  a  given 
time  with  previous  pregnancies.  Ask  whether  they  have  been 
observe* I  this  time  since  the  patient  first  noticed  the  enlargement 
of  the  abdomen. 

Quickening  is  usually  noticed  at  the  end  of  the  sixteenth  week 
of  pregnancy.     The  signs  of  pregnancy  in  the  later  months  are 


FIG.  130. — The  Height  of  the  Fundus  Uteri  at  the  Various  Weeks  of  Pregnancy 

(After  Zweifel.) 

softening  of  the  cervix,  increased  vaginal  discharge1,  ballottement 
after  the  twenty-first  week.  Fluctuation  in  the  uterus  is  very 
indistinct  unless  the  liquor  amnii  is  in  excess  and  the  uterine  walls 
are  thin  from  any  cause.  By  careful  palpation  the  intermittent 
rhythmical  contractions  of  the  pregnant  uterus  may  be  felt  as 
early  as  the  fourth  month.  A  good  deal  of  patience,  gentleness, 
and  skill  are  necessary  to  get  this  sign.  Purplish  discoloration 


LARGE  OVARIAN  TUMORS 


307 


of  the  vulva  and  anterior  wall  of  the  vagina  are  to  be  made  out  from 
the  sixth  to  the  twelfth  week.  If  milk  or  colostrum  can  be  squeezed 
from  the  breasts  it  is  an  important  indication  of  pregnancy. 

Fetal  heart  sounds  can  be  heard  after  the  twentieth  week,  and 
fetal  movements  can  be  felt  after  the  sixteenth  week  unless  the 
fetus  is  dead.  The  tumor  has  developed  relatively  rapidly;  there 
is  pigmentation  of  the  areolse  of  the  nipples,  and  of  the  linea  alba 
in  some  cases;  edema  of  the  ankles  is  not  uncommon  after  the 


FIG.  131. — The  Abdomen  of  Ascites  Seen  in  Profile.     (Kelly.) 

seventh  month:  the  face  shows  sometimes  the  facies  uterina,  a 
fullness  about  the  eyes  and  front  of  the  cheeks. 

In  the  case1  of  an  ovarian  tumor  there  is  no  softening  of  the 
cervix:  the  tumor  is  distinct  from  the  uterus  and  is  of  gradual 
development;  there  is  no  ballottement  and  there  are  no  fetal  heart 
sounds  or  movements:  also  there  is  absence  of  pigmentation  of  the 
areohe  and  the  linea  alba:  edema  of  the  ankles  is  rare,  except  after 
a  tumor  has  existed  several  years;  the  superficial  veins  of  the 
abdomen  are  enlarged,  and  the  facies  ovarina  is  present  in  the 
case  of  long-existing  tumors. 

Hydramnios,  an  excess  of  amniotic  fluid,  has  led  many  a  surgeon 
to  diagnose  ovarian  cyst.  A  careful  study  of  the  history,  symp- 
toms and  signs  of  pregnancy  and  ovarian  tumor  ought  to  make 


308  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

differentiation  relatively  easy  and  sure.  In  ovarian  cyst  the 
tumor  is  of  less  rapid  development,  there  is  no  ballottement,  and 
the  tumor  is  more  on  one  side  than  the  other,  and,  most  important, 
it  is  distinct  from  the  uterus. 

2.  Ascites. — An  accumulation  of  fluid  in  the  peritoneal  cavity 
may  accompany  an  ovarian  tumor,  and  in  such  a  case  the  diagnosis 
is  difficult,  and  may  be  settled  exactly  only  at  the  operation  under- 
taken for  the  removal  of  the  tumor. 

The  following  table,  taken  from  Dudley's  "Gynecology,"  with 
modifications,  gives  the  points  which  serve  usually  to  distinguish 
ascites  from  ovarian  cyst. 


Ascites. 

1.  Previous    history    of    disease    of 
kidneys,  heart,  or  liver,  or  peritoneum. 

2.  Enlargement  comparatively  sud- 
den. 

3.  Face   puffy;     color  waxy;    early 
anemia. 

4.  With   patient  in   dorsal   position 
symmetrical  enlargement  of  abdomen, 
bulging  in  flanks  and  flat  on  top. 

5.  With  patient  sitting  the  abdomen 
bulges  below. 

6.  Navel  prominent  and  thinned. 

7.  Fluctuation   decided   and   diffuse 
throughout  abdomen,  but  is  absent  in 
the  highest  parts.     Modified  on  change 
of  position. 

8.  Intestines  float  on  top  of  liquid, 
therefore  percussion  gives  a  tympanitic 
note  in  the  upper  portions  and  flatness 
in  the  flanks  when  patient  is  on  her 
back.     Change  in  position  changes  po- 
sition of  intestines    and   of   resonance 
to  the  highest  part  of  the  abdomen. 

9.  Vaginal  palpation  shows  bulging 
into  the  posterior  cul-de-sac. 

]().  Uterus   prolapsed,  but  size  and 
mobility  unchanged. 


Large  Ovarian  Cyst 

1.  No  such  history 

2.  Gradual. 

3.  Facies  ovarina,  anemia  relatively 
late. 

4.  Asymmetrical  until  tumor  is  very 
large,  peaked  on  top. 

5.  No  change. 

6.  Navel  unchanged  usually. 

7.  Less  distinct  and  limited  to  the 
cyst.     Not  modified  by  change  in  po- 
sition of  patient. 

8.  Intestines  occupy  same  position 
all  the  time.     No  change  in  percussion 
with  change  in  position  of  patient,  i.e., 
flat  over  cyst   and  resonant  above  it 
and  to  one  side,  the  side  opposite  to 
that  from  which  the  cyst  sprung. 

9.  No  bulging  into  the  cul-de-sac. 

10.  Uterus   displaced   by   the    cyst, 
mobility  limited  by  the  tumor. 


Encyxtcii  (txcilex,  or  fluid  confined  to  a  limited  part  of  the  alv 
dominal  cavity  by  adhesions,  may  give  the  same  areas  of  dullness 
and  resonance  as  an  ovarian  cyst. 


LARGE  OVARIAN   TUMORS 


309 


3.  Fibroids. — There  is  considerable  clanger  of  confusing  a  large 
fibromyoma  of  the  uterus  with  a  large  ovarian  cyst.  The  following 
table,  compiled  from  several  authors  and  from  my  own  experience, 
points  out  the  chief  features  in  the  differential  diagnosis: 


Large  Uterine  Fibroid. 

1.  Menorrhagia      or      metrorrhagia 
common  where  the  growth  is  intersti- 
tial in  part. 

2.  General  health  not  necessarily  im- 
paired,   except    anemia    from    loss   of 
blood  or  debility  from  pain.     Palpita- 
tion of  heart  common. 

3.  Rarely  occurs  in  early  life. 

4.  Slow  growth. 

5.  Apt  to  be  asymmetrical  and  nodu- 
lar; tumors  commonly  multiple. 

6.  Consistency  firm,  elastic,  or  hard. 

7.  Uterus  large  and  cavity  enlarged 
if  growth  is  interstitial.     Tumor  a  part 
of  uterus  or  connected  by  a  short  and 
thick  pedicle. 

8.  Uterine  bruit  by  auscultation  in 
half  of  the  cases. 

9.  No  change  in  facial  expression  un- 
less pale  from  hemorrhage. 

10.  Superficial  veins  of  abdomen  not 
enlarged. 


Large  Ovarian  Cyst. 

1.  Menstruation  unchanged  or  dimin- 
ished in  amount. 

2.  General    health    impaired    early. 
No  pain  except  in  the  case  of  adhesions, 
or    other    complications.     Palpitation 
uncommon. 

3.  May  occur  in  infancy. 

4.  More  rapid  growth. 

5.  Symmetrical;    may  be  lobulated. 

6.  Fluctuating. 

7.  Uterus  not  enlarged.     Tumor  con- 
nected with  it  only  by  pedicle,  which  is 
apt  to  be  relatively  long. 

8.  Absent. 

9.  Facies  ovarina  and  loss  of  flesh 
about  neck  and  chest. 

10.  Veins  enlarged. 


It  must  not  be  forgotten  that  because  of  degenerative  proc- 
esses in  a  uterine  fibroid  there  may  be  fluid  in  the  tumor  and 
fluctuation  will  be  found,  and  that  in  some  of  the  ovarian  tumors 
with  solid  contents  fluctuation  may  be  absent.  As  stated  before,  it 
is  never  justifiable  to  tap  a  tumor,  a  procedure  once  much  in  vogue 
for  the  purpose  of  diagnosis,  because  some  of  the  fluid  is  almost 
sure  to  escape  into  the  peritoneal  cavity  and  to  cause  peritonitis 
of  a  grade  and  severity  depending  on  the  character  and  amount 
of  fluid  extra  vacated. 

4.  Accumulation  of  Gas  or  Fecal  Matter  in  the  Intestines. — Tym- 
panites has  been  mistaken  for  ovarian  cyst.  Accumulated  gas 
gives  a  tympanitic  note  on  percussion,  the  gurgling  of  gas  in  the 
bowels  may  be  heard  by  auscultation,  and  there  is  an  absence  of 
a  fluid  wave  on  palpation.  By  the  vaginal  touch  there  is  an 


310 


DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 


absence  of  the  firm  elasticity  communicated  by  a  fluid  or  solid 
tumor.  In  the  case  of  fecal  accumulation  there  is  a  history  of 
chronic  constipation  and  the  distended  bowel  will  pit  on  pressure 
by  abdominal  or  vaginal  touch.  Active  catharsis  removes  the 
tumor. 

5.  Fat  or  Tumors  in  the  Abdominal  Walls,  including  "Phantom 
Tumor." — A  thick  panniculus  adiposus  may  simulate  an  ovarian 
tumor  and,  strange  as  it  may  seem,  well-known  surgeons  have  oper- 
ated for  tumor  under  such  conditions.  Grasping  the  abdominal 
walls  in  the  hands,  it  is  possible  in  most  cases  to  determine  that 
the  fat  is  in  the  substance  of  the  wall  rather  than  in  the  abdominal 
cavity.  Edema  of  the  abdominal  walls  sometimes  simulates 

Central  part  of  abdomen 
Tympanitic 


FIG.   132. — Diagram   of  a   Cross   Section   of  the  Abdomen   of  Ascites,   Dorsal 

Position. 

tumor.  In  this  case  we  expect  to  find  pitting  on  pressure  and 
evidences  of  edema  elsewhere. 

Tumors  of  the  anterior  abdominal  walls  consist  of  fibromyoma 
of  the  rectus  muscle  and  cysts  of  the  urachus.  They  are  of  un- 
common occurrence. 

Fibromyoma  of  the  Rectus. — Two  instances  of  this  have  fallen  under 
my  observation.  Both  patients  were1  twenty-nine  years  of  age  and 
mothers  of  families.  ( )ne  was  seen  with  Dr.  F.  W.  Johnson,  of  Bos- 
ton, in  consultation,  March  IS,  1892,  and  operated  upon  by  him  the 
same  day  in  my  presence.  Here  there  was  a  tumor  of  soft  consist- 
ency, the  size  of  a  Florida  orange,  in  the  left  epigastric  region.  The 
other  was  a  patient  operated  upon  by  me  October  23,  1S96.  In 
this  case  there  was  a  somewhat  smaller  tumor  of  harder  consistency 
in  the  right  rectus  muscle,  just  below  the  level  of  the  umbilicus. 


LARGE  OVARIAN  TUMORS 


311 


Both  were  entirely  extraperitoneal  and  were  pronounced  by  the 
pathologist  to  be  fibromyoma. 

Cysts  of  the  urachus  develop  in  the  normally  impervious  cord 
which  runs  from  the  bladder  to  the  umbilicus.  Like  the  bladder 
itself,  a  cyst  of  the  urachus  represents  a  persistent  portion  of  the 
allantois.  A  cyst  as  large  as  the  urinary  bladder,  or  larger,  may 
form  in  the  course  of  the  urachus.  Such  a  cyst  is  situated  between 
the  fascia  and  the  peritoneum  on  the  inside  of  the  abdominal 
parietes,  in  the  median  line.  It  is  to  be  differentiated  from  an 
ovarian  cyst  by  its  absence  of  connection  with  the  uterus  or  its 
appendages,  by  the  greater  area  in  the  abdomen  of.  intestinal 


Formerly  dull, 
now  tympanitic 


FIG.  133. — The  Same  as  Fig.  132,  Lateral  Position,  Showing  Change  in  Situation 
of  Areas  of  Dullness  and  Tympany. 

resonance,  and  by  the  absence  of  the  other  signs  and  symptoms 
of  ovarian  cyst. 

11  PJiantom  Tumor." — Phantom  tumor  occurs  occasionally  in 
hysterical  women  who  have  the  power  of  contracting  the  muscles 
of  the  abdomen  so  as  to  form  a  mass  that  simulates  an  abdominal 
tumor.  The  muscular  contraction  can  be  overcome  sometimes 
in  these  cases  by  firm  pressure  of  the  hands  and  the  tumor  then 
disappears.  There  is  exaggerated  tympany  over  the  tumor  be- 
cause the  intestines,  held  by  the  muscles,  form  the  tumor.  In 
many  cases  it  is  impossible  to  make  an  exact  diagnosis  without 
etherization,  and  accordingly  it  is  well  to  etherize  a  doubtful  case 
of  phantom  tumor  or  tumor  in  the  abdominal  wall. 

6.  Cyst  of  the  Pancreas. — The  >ituation  of  the  tumor  is  of  great 
importance  in  differentiating  cyst  of  the  pancreas  from  ovarian 
cyst.  The  former  develops  under  the  margin  of  the  ribs  on  the  left 


312  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

side  and  grows  from  above  downward.  If  the  cyst  is  large  the 
liver  and  stomach  may  be  displaced  upward,  while  the  transverse 
colon  is  depressed  under  the  tumor,  the  cyst  reaching  the  pelvis 
only  exceptionally  in  the  case  of  very  large  tumors.  Therefore  a 
pancreatic  cyst  can  be  confused  only  with  high-lying  ovarian  cyst. 
Pancreatic  cysts  generally  arc  thin-walled  and  the  fluid  is  thin, 
consequently  fluctuation  is  marked.  The  greatest  convexity  of 
the  abdomen  is  in  the  neighborhood  of  the  umbilicus.  The  history 
given  by  the  patient  is  that  the  tumor  was  high  up  under  the  ribs 
when  first  noticed,  and  bimanual  examination  of  the  pelvic  organs 
shows  that  there  is  no  connection  between  the  uterus  and  the 
tumor  and  that  the  ovaries  are  not  enlarged. 

7.  Tumors  of  the  Spleen,  Liver,  and  Kidneys.— Tumors  of  the  spleen 
originate,  of  course,  in  the  left  hypochondrium,  have  an  oblique  posi- 
tion, and  a  peculiar  elastic  consistency.  Under  the  influence  of  de- 
generative processes  or  the  presence  of  an  echinococcus  cyst  there 
may  be  fluid  in  a  splenic  tumor.  Such  a  condition  must  be  re- 
garded as  very  unusual,  however.  In  the  case  of  wandering  spleen 
the  tumor  may  be  in  the  iliac  fossa,  and  may  be  mistaken  for  an 
ovarian  tumor  or  a  kidney.  Careful  palpation  of  such  a  tumor 
with  the  aid  of  an  anesthetic  will  show  one  or  more  notches  in  the 
anterior  border  and  perhaps  a  vertical  slit  at  the  hllum.  Palpa- 
tion of  the  kidney  regions  will  show  the  presence  of  the  kidneys 
in  their  normal  situation.  It  has  been  suggested  by  H.  A.  Kelly 
(Kelly  and  Noble,  "Gynecology  and  Abdominal  Surgery,"  Vol.  II., 
p.  597)  that  by  passing  a  renal  catheter  and  injecting  the  kidney 
with  enough  fluid  to  produce  a  mild  renal  colic,  the  pain  will  be  re- 
ferred to  the  lumbar  region  and  not  to  the  splenic  tumor.  Exami- 
nation of  the  pelvic  organs  ought  to  exclude  uterus,  tubes,  and 
ovaries  from  participation  in  the  tumor.  A  wandering  spleen  has 
been  known  to  become  lodged  in  the  pelvis  and  there  to  obstruct 
the  intestine  (case  of  Korte,  cited  by  .1.  Bland-Sutton,  Brit.  Med. 
Jour.,  1897,  p.  132),  and  J.  C.  Webster  (Jour.  Amcr.  Med.  Asso., 
1903,  Vol.  XL.,  p.  887)  has  reported  a  case  of  wandering  spleen 
that  occupied  the  right  iliac  fossa. 

Tumors  of  the  liver  may  be  confused  with  ovarian  tumors  if 
they  reach  downward  to  the  pelvis,  or  if  during  late  pregnancy 
an  ovarian  tumor  has  become  fixed  to  the  liver  by  adhesions,  so 
that  upon  involution  of  the  uterus  the  tumor  remains  in  the  upper 


LARGE  OVARIAN  TUMORS  313 

abdomen.  The  firm,  hard  consistency  of  the  liver  is  more  or  less 
characteristic,  also  its  sharp  lower  border,  which  is  placed  obliquely 
to  the  ensiform  cartilage  and  is  indented  with  a  notch  for  the  gall 
bladder.  Also,  all  liver  tumors  move  more  or  less  on  deep  respira- 
tion, except  accessory  lobes,  very  large  tumors,  and  echinococcus 
disease.  The  pelvic  organs  are  investigated  and  the  relation  of 
the  tumor  to  the  liver  tested  by  moving  the  tumor  about  and 
noticing  if  the  liver  is  moved  also. 

Tumors  of  the  kidney  are  not  of  frequent  occurrence.  The  most 
common  are:  hypernephroma  and  papillary  cystoma.  Malignant 
tumors  affect  especially  the  young  and  the  old.  Hematuria  is 
present  in  almost  all  malignant  tumors  of  the  kidney;  pain  in  the 
region  of  the  kidney  is  a  less  common  symptom.  Hypernephroma 
is  a  tumor  arising  from  adrenal  tissue  but  involving  the  kidney  in 
practically  all  instances.  The  tumor  is  lobulated  and  extends 
toward  the  median  line.  It  is  malignant  and  has  metastases, 
most  commonly  in  the  lungs  and  liver. 

Polycystic  disease  of  the  kidney  consists  of  a  cystic  degeneration 
of  the  kidney  parenchyma,  and  the  tumor  is  like  a  bunch  of  grapes. 
Many  of  these  tumors  are  congenital.  Congenital  kidney  disease 
is  apt  to  be  associated  with  disease  of  the  ovaries,  as  the  two  de- 
velop together  in  fetal  life.  Echinococcus  cysts  develop  in  the 
kidney  in  5.8  per  cent  of  all  cases  of  hydatid  disease.  The  tumor 
grows  slowly  and  forms  a  smooth,  round,  movable  mass. 

A  movable  kidney  may  get  as  low  as  the  pelvis.  Its  shape  is 
characteristic.  Hydronephrosis  may  accompany  renal  tumor  and 
in  this  case  the  urine  will  show  abnormal  constituents. 

Cystic  tumors  or  simple  cysts  of  the  kidney  arise  in  the  outer  part  of 
the  cortex,  and  may  attain  great  size.  Such  a  cyst  is  to  be  differen- 
tiated from  an  ovarian  cyst  by  its  location  in  the  flank,  its  relative 
immobility,  and  by  it.s  not  being  connected  with  the  uterine  organs 
as  proved  by  the  bimanual  examination.  If  the  uterine  organs  are 
normal  the  differentiation  is  easier  than  if  they  are  diseased. 

8.  Cyst  of  the  Omentum. — Cysts  of  the  omentum  are  mostly  flat 
and  shield-shaped;  they  are  very  freely  movable,  and  can  be  ro- 
tated so  that  in  some  cases  the  posterior  portion  of  the  cyst  may 
be  palpated.  They  are  of  infrequent  occurrence,  and  it  is  gener- 
ally easy  to  determine  that  the  cyst  has  no  connection  with  the 
uterine  organs. 


314  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

9.  Echinococcus  Cysts. — Echinocoecus  disease  may  be  confused 
with  ovarian  tumor  especially  if  it  involves  structures  in  the  pelvis. 
It  has  been  referred  to  as  occurring  in  the  liver,  spleen,  and  kid- 
neys.    In  the  pelvis  it  occurs  in  the  following  situations  according 
to  Bland-Sutton  (''Diseases  of  Women,"  Bland-Button  and  Giles, 
p.  388):  («)  The  uterus;  (b)  the  mesometrium ;  (c)  the  pelvic  bones; 
(d)  the  omentum;  (e)  the  Fallopian  tubes.     There  is  no  authentic- 
case  on  record  of  primary  echinococcus  cyst  of  the  ovary.     Large 
tumors  may  develop  in  any  of  the  structures  named.     As  a  rule, 
they  form  part  of  a  general  invasion  of  the  subperitoneal  tissues. 
The  colonies  are  apt  to  communicate  with  the  vagina,  bladder,  or 
rectum  and  the  characteristic  vesicles  escape  with  the  urine  or  feces. 
Bland-Sutton  says,  "The  clinical  recognition  of  echinococcus  cysts 
in  the  pelvic  organs,  mesometrium,  or  bones  is  sometimes  made  by 
a  sort  of  'lucky  guess'  when  other  and  more  common  diseases  can 
with   certainty  be  excluded.     Occasionally  when  a  patient  seeks 
advice  for  pelvic  trouble,  and  brings  'vesicles'  which  have  escaped 
by  the  rectum,   vagina,   or  urethra,  much  speculation  is  spared. 
When  the  bones  are   eroded  and  swellings  form  under  the  skin, 
they   are   punctured,  ami   characteristic    fluid   with   vesicles   and 
hooklets  escapes,  and  so  the  diagnosis  is  established.     When  the 
cysts  suppurate  the  physical  signs  are  those  of  abscess." 

10.  Dilated    Stomach. — Careful   percussion  of  the  stomach  area, 
auscultation  of  the  abdomen  while  the  patient  swallows  a  mouth- 
ful of  water,  the  appreciation  of  a  gurgling  sound  all  over  the  region 
occupied  by  the  stomach,  and  the  situation  of  the  maximum  of 
enlargement  of  the  abdomen  above  the  umbilicus,  ought  to  deter- 
mine the  presence  of  a  dilated  stomach.     If  there  is  a  doubt  ad- 
minister an  effervescent  mixture  and  practice  percussion  when  the 
stomach  is  distended  with  gas. 

11.  Distended  Urinary  Bladder. — The  bladder  may  rise  as  high 
as  the  umbilicus  when  overdistended  and  may  present  the  appear- 
ance of  an  ovarian  cyst.     (See  Fig.  85,  page  217.)     The  bladder 
tumor  is  in  the  median  line,  close  held  to  the  back  of  the  arch  of 
the  ptibes;  it  bulges  into  the  vagina,  distending  the  anterior  wall: 
there  is  almost  continuous  overflow  of  urine,  and  generally  hypo- 
gastric   distress,   except   where  the   patient   is  unconscious  or  the 
distention  has  existed  a  long  time.     Passing  the  catheter  removes 
all  doubt. 


COMPLICATIONS  OF  OVARIAN  TUMORS  315 


DIAGNOSIS  OF  THE  COMPLICATIONS  OF  OVARIAN  TUMORS 

The  complications  to  which  ovarian  tumors  are  subject  are: 

1.  Adhesions  and  incarceration. 

2.  Intraligamentous  development. 

3.  Torsion  of  the  pedicle. 

4.  Infection  and  suppuration. 

5.  Degenerative  processes,  including  malignancy. 

6.  Rupture. 

7.  Association  with  pregnancy. 

i.  Adhesions  and  Incarceration. — Adhesions  between  an  ovarian 
tumor  and  its  surrounding  structures  make  the  diagnosis  much 
more  difficult,  especially  in  the  case  of  small  ovarian  tumors,  those 
lying  wholly  within  the  cavity  of  the  pelvis.  The  history  of  at- 
tacks of  inflammation  may  give  a  clew  to  the  presence  of  adhesions, 
as  the  occurrence  of  pain.  It  is  a  well-known  fact  that  the  parietal 
peritoneum  rather  than  the  visceral  peritoneum  is  the  seat  of 
pain.  This  fact  has  been  demonstrated  during  abdominal  opera- 
tions performed  under  local  anesthesia.  Therefore  we  should 
expect  adhesions  to  the  parietal  peritoneum  to  cause  more  pain 
than  those  to  the  viscera.  Extensive  adhesions  may  occur  with- 
out any  pain  whatsoever. 

Fixation  of  a  tumor  to  a  greater  or  less  degree  indicates  adhesions 
as  a  rule.  The  exception  is  the  rare  condition  of  incarceration 
ivithout  adhesions.  A  tumor  may  become  incarcerated  in  the 
pelvis,  thus  causing  obstruction  of  the  bowel,  or  abortion  as  in  the 
case  of  the  retro  flexed  pregnant  uterus. 

An  attempt  should  be  made  to  dislodge  an  ovarian  tumor  fixed 
in  the  pelvis,  by  putting  the  patient  in  the  knee-chest  position, 
letting  air  into  the  vagina  by  means  of  the  Sims  speculum,  and  by 
making  traction  on  the  cervix  with  a  tenaculum.  Upward  pressure 
on  the  tumor,  the  patient  being  in  the  dorsal  position,  through 
either  the  vagina  or  rectum  will,  in  many  cases,  dislodge  a  non- 
adherent  tumor.  After  reposition  the  bimanual  palpation  and  the 
mapping  out  of  the  pedicle  proceed  with  greater  facility.  Some- 
times the  shape  and  character  of  adhesions  in  the  pelvis  can  be 
made  out  by  touch,  also  adhesions  to  the  abdominal  walls  in  the 
case  of  large  tumors  can  be  determined  in  a  smaller  proportion  of 


316  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

cases.  Adhesions  to  the  intestines,  omentum,  liver,  or  spleen  can 
not  be  diagnosed  with  certainty. 

2.  Intraligamentous  Development. — If  a  tumor  has  grown  between 
the  layers  of  the  broad  ligament  it  is  immovable  and  can  not  be 
displaced  into  the  abdominal  cavity  by  bimanual  manipulation. 
It  gives  the  impression  of  being  closely  united  with  the  uterus  and 
the  examiner  may  receive  the  impression  that  he  has  to  do  with  a 
fibroid  tumor  of  the  uterus.  Intraligamentous  tumors  are  gen- 
erally cystic,  however;  they  have  no  pedicle  and  sometimes  may 
be  differentiated  from  parovarian  cysts  by  this  characteristic. 

If  the  physician  can  decide  that  an  immovable  cystic  tumor  in 
the  pelvis  is  connected  not  only  with  the  uterus  but  with  the  side 


FIG.  134. — Diagram  Showing  the  Course  of  the  Utero-sacral  Ligaments  in  the 
Case  of  a  Retro-peritoneal  Tumor. 

of  the  uterus  the  tumor  is  probably  an  intraligamentous  ovarian 
cyst.  This  may  be  done  sometimes  by  grasping  the  uterus  and 
palpating  it  separately  from  the  tumor.  The  uterus  is  commonly 
displaced  laterally  to  the  side  of  the  pelvis  opposite  to  that 
occupied  by  the  tumor.  Occasionally  the  ovary  with  its  long 
Fallopian  tube  stretching  to  it  as  a  cord  may  be  made  out  lying 
on  the  top  of  the  tumor,  and  now  and  then  the  round  ligament 
can  be  palpated  as  a  round  cord  coming  over  the  surface  of  the 
tumor  to  the  internal  abdominal  ring. 

To  distinguish  a  tumor  developing  under  the  peritoneum  in  the 
back  of  the  pelvis  from  an  intraligamentous  tumor  one  tries  to 
palpate  the  utcro-sacral  ligaments.  If  these  are  in  front  of  the 
tumor  it  is  a  retro-peritoneal  growth,  whereas  if  the  ligaments 


COMPLICATIONS  OF  OVARIAN  TUMORS 


317 


are  behind  the  tumor  it  is  an  intraligamentous  neoplasm.     (See 
Figs.  134  and  135.) 

3.  Torsion  of  the  Pedicle. — Rotation  of  an  ovarian  tumor  on  its 
long  axis  causing  twisting  of  its  pedicle  is  by  no  means  an  uncom- 
mon happening.  It  presupposes  the  absence  of  adhesions  to  sur- 
rounding fixed  structures  such  as  the  pelvic  walls  or  the  parietes 
of  the  abdomen.  It  is  more  apt  to  occur  in  tumors  of  medium  size. 
To  detect  a  twisting  by  palpation  of  the  pedicle  where  all  the  con- 
ditions are  most  favorable  is  a  possibility.  Ordinarily  torsion  is 
diagnosed  only  by  its  results.  The  twisting  may  be  gradual,  in 
which  case  the  tumor  adjusts  itself  to  the  lessened  blood  supply 
caused  by  the  constriction  of  its  pedicle,  or  it  may  be  rapid. 


-sacral 
ligament- 


"/-tften/s. 


FIG.  135. — Diagram  Showing  the  Course  of  the  Utero-sacral  Ligaments  in  the 
Case  of  an  Intra-ligamentous  Tumor. 

Whether  gradual  or  rapid  there  comes  a  time  when  the  blood  supply 
is  cut  off,  then  ensue  in  the  cyst  edema,  enlargement,  suppuration, 
or  even  gangrene.  Atrophy  has  been  known  to  occur  in  the  case 
of  very  small  tumors  and  complete  separation  of  the  cyst  from  its 
pedicle  in  rare  instances.  Torsion  is  apt  to  be  followed  by  adhe- 
sions, especially  adhesions  to  the  bowels. 

Symptoms  of  the  chronic  stage  of  torsion  may  be  entirely  want- 
ing, or  a  patient  may  complain  of  pains  in  the  abdomen  especially 
at  the  time  of  the  catamenia  when  congestion  of  the  pelvic  organs 
is  normally  greatest.  These1  pains  may  be  associated  with  nausea 
and  vomiting  and  are  apt  to  follow  violent  exertion  or  trauma.  If 
the  twisting  is  sufficient  to  cause  blood  stasis  the  symptoms  are 
those  of  general  peritonitis  and  there  is  present  an  acute  abdominal 


318  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

emergency.  Acute  abdominal  pain,  rapid,  feeble  pulse,  vomiting, 
elevation  of  temperature,  and  a  rigid  abdomen  occurring  in  a  woman 
known  to  have  an  ovarian  tumor  are  symptoms  calling  for  im- 
mediate operation. 

Twisting  of  a  pedicle  of  an  ovarian  tumor  has  been  mistaken 
for  appendicitis.  Bimanual  examination  will  reveal  the  presence 
of  the  ovarian  tumor;  the  pain  caused  by  torsion  is  not  of  the  colicky 
character  of  the  pain  of  appendicitis.  Finally  the  history  reveals 
no  similar  attacks  of  pain  and  no  history  of  digestive  disturbances 
and  irregularity  of  the  bowels  as  in  the  case  of  appendicitis. 

4.  Infection  and  Suppuration. — Infection  of  ovarian  tumors  with 
streptococcus,  typhoid  bacillus,  or  bacterium  coli  communis,  is 
transmitted  by  the  blood  current,  or  from  the  intestine,  urinary 
bladder,  or  the  Fallopian  tube.     Formerly,  when  it  was  the  custom 
to  tap  ovarian  cystomata,  infection  was  introduced  very  frequently 
in  this  way.     Ovarian  cysts  become  infected  following  an  attack 
of  typhoid  fever,  and  in  this  case  the  bacilli,  in  all  probability,  gain 
entrance  through  the  blood.     A  patient  known  to  have  an  ovarian 
cyst  should  be  watched  carefully  for  evidence  of  infection  of  the  cyst 
following  an  attack  of  typhoid  fever.     The  symptoms  are  chills, 
elevation  of  temperature,  rapid  pulse,  pain,  and  tenderness  in  the 
abdomen. 

The  Fallopian  tube  is  a  very  frequent  carrier  of  infection  to  an 
ovarian  tumor.  This  is  to  be  inferred  because  it  is  about  the 
fimbriated  end  of  the  Fallopian  tube  that  the  densest  adhesions 
are  to  be  found  during  operation  for  the  removal  of  infected  cysts. 
It  is  probable  that  infection  following  puerperal  fever  reaches  a 
tumor  by  this  channel.  In  the  case  of  an  inflamed  bladder  or  in- 
testine or  vermiform  appendix  the  organ  may  become  adherent 
to  a  tumor  and  the  inflammatory  process  be  carried  to  the  growth 
by  continuity.  The  inflammatory  process,  however  transmitted, 
may  go  on  to  suppuration.  In  this  case  there  are  to  be  noted 
sudden  enlargement  of  the  cyst,  severe  pain  and  tenderness,  rapid 
and  weak  pulse,  and  chills,  high  temperature,  and  exhaustion. 
Prompt  operation  alone  will  prevent  rupture  or  general  peritonitis 
and  death.  Gas  may  be  formed  in  the  cyst  and  then  a  tympanitic 
note  will  be  given  to  the  percussion  over  it. 

5.  Degenerative  Processes  Including  Malignancy. — The  following 
secondary  changes  may  take  place  in  an  ovarian  tumor,  although 


COMPLICATIONS  OF  OVARIAN  TUMORS  319 

none  of  them  can  be  diagnosed  with  certainty.  On  account  of  the 
necessity  of  speedy  operation  indications  of  malignancy  require 
special  attention,  however. 

(a)  Calcareous  degeneration. 

(6)  Fatty  degeneration. 

(c)  Myxomatous  degeneration. 

(d)  Changes  in  the  fluid  contents  from  straw  color — with  specific 
gravity  of  from  1010  to  1050 — to  thick  or  semisolid,  of  various 
colors  and  consistencies. 

(e)  Malignant    degeneration.      Carcinoma,   sarcoma,   endothe- 
lioma,  and  teratoma  are  the  malignant  processes  affecting  ovarian 
tumors.     Suspicion  of  malignity  attaches  to  double-sided  tumors, 
i.e.,  tumors  of  both  ovaries,  and  to  partial  development  in  the 
broad  ligament.     Ascites  is  common  in  the  case  of  malignant 
tumors,  and  is  apt  to  be  small  in  amount  except  in  the  late  stages 
of  the  disease.     Malignant  tumors,  except  sarcoma,  are  most  apt 
to  occur  in  old  rather  than  in  young  women,  and  cachexia  is  found 
in  the  later  stages  only.     Early  edema  of  the  legs  in  the  case  of  small 
tumors  is  said  to  be  a  sign  of  malignancy.     When  the  disease  has 
attacked  the  surface  of  the  tumor  hardness  of  the  tissues  and  a 
nodular  feeling  by  both  abdominal  and  vaginal  palpation  is  most 
characteristic.     The  nodules   or  lumps  may   be  large  or  small. 
The  surface  is  irregular.     It  should  not  be  forgotten  that  cancer 
of  the  ovaries  is  very  often  metastatic  and  that  the  primary  seat 
of  the  disease  should  be  sought  in  the  stomach  or  intestine. 

6.  Rupture. — Rupture  of  an  ovarian  cyst  is  of  unusual  occurrence, 
especially  in  these  days  of  relatively  early  operation  on  women 
who  have  tumors.  In  the  older,  preaseptic  days,  when  the  danger 
of  operation  was  great,  many  cysts  ruptured  and  filled  again  or 
caused  pen-it  on  it  is  as  it  happened.  The  physician  and  also  the 
nurse  should  remember  that  a  thin-walled  cyst  or  one  having  weak 
places  in  its  walls  because  of  degenerative  processes  may  be  rup- 
tured by  a  too  vigorous  bimanual  examination  or  by  preparations 
for  an  abdominal  operation.  Both  of  these  accidents  have  occurred 
in  my  experience.  In  the  case  of  a  multilocular  cyst  only  one 
loculus  may  rupture  and  the  rupture  may  be  into  the  main  cyst 
cavity,  into  another  loculus,  or  into  any  one  of  the  following  struc- 
tures: peritoneal  cavity — most  frequent — and  bladder,  vagina,  or 
rectum.  Rarely  rupture  has  occurred  into  the  small  intestine,  or 


320  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

Fallopian  tube,  and  very  rarely  through  the  abdominal  wall  or  into 
the  stomach.  The  causes  of  rupture  are,  degenerations  of  the  cyst 
wall;  papillomatous  growths  penetrating  the  wall;  torsion  of  the 
pedicle,  causing  hemorrhage  or  suppuration  in  the  cyst  with  in- 
creased tension ;  and  trauma,  such  as  blows  on  the  abdomen,  care- 
less handling,  already  referred  to,  or  contractions  of  the  abdominal 
walls  in  labor.  Parovarian  cysts  when  once  ruptured  may  not 
refill.  In  the  case  of  ovarian  cysts  the  wall  continues  to  secrete 
fluid  after  rupture  and  the  cyst  may  refill  or  the  fluid  may  be 
poured  into  the  organ  into  which  the  opening  has  been  made. 
If  the  fluid  is  clear  and  serous  it  may  cause  little  irritation  of  the 
peritoneum;  if,  on  the  other  hand,  it  is  colloid  or  dermoid  in  char- 
acter it  is  apt  to  set  up  a  lively  peritonitis.  The  gravity  of  rupture 
depends  then,  in  large  measure,  on  the  character  of  the  cyst  con- 
tents. This  being  unknown,  the  complication  must  be  regarded 
as  serious  and  treated  by  immediate  operation,  for  rupture  of  an 
infected  cyst  into  the  peritoneal  cavity  is  usually  fatal. 

The  symptoms  are  severe  pain  in  the  abdomen,  faintness,  rapid 
pulse,  perhaps  subnormal  temperature.  Examination  shows  ab- 
sence of  the  tumor  and  free  fluid  in  the  peritoneum,  or  discharge  of 
fluid  from  bladder,  vagina,  or  rectum,  or  other  viscus.  If  only  one 
loculus  has  been  ruptured  the  tumor  will  be  diminished  in  size 
only  by  so  much. 

7.  Association  with  Pregnancy. — Small  or  medium-sized  tumors 
are  more  often  found  in  association  with  pregnancy.  Because  of 
the  danger  of  rupture  and  torsion  of  the  pedicle,  the  diagnosis 
of  pregnancy  in  these  cases  is  of  the  greatest  importance.  In  the 
early  months  it  is  a  question  of  determining  the  presence  of  more 
than  one  growth  in  the  pelvis  or  a  tumor  on  each  side,  one  being  the 
uterus  and  the  other  the  ovarian  tumor.  The  signs  of  pregnancy 
are  referred  to  in  Chapter  XXII. ,  p.  420.  If  physicians  would 
make  it  a  rule  to  examine  all  pregnant  women  under  their  care 
from  time  to  time  with  reference  to  the  detection  of  tumors  and 
other  abnormalities,  many  of  the  tragedies  of  the  puerperium 
would  be  avoided.  In  cases  of  doubt  it  is  advisable  to  administer 
ether  in  order  to  make  a  diagnosis. 


PATHOLOGICAL  VARIETIES  OF  OVARIAN  TUMORS          321 


DIAGNOSIS    OF    THE    DIFFERENT    PATHOLOGICAL    VARIETIES    OF 

OVARIAN  TUMORS 

The  different  kinds  of  ovarian  tumors  according  to  their  patho- 
logical characteristics  are  shown  in  the  list  on  page  291.  Prognosis 
and  treatment  depend  in  a  measure  on  the  kind  of  tumor  present; 
therefore,  certain  probabilities  may  be  stated  as  to  the  different 
tumors.  The  following  description  is  taken  with  few  changes 
from  Winter's  "  Gynaekologischen  Diagnostik,"  p.  303. 

1.  Follicular  cysts  never  occur  larger  than  a  base-ball.    They  are 
unilocular,  have  thin  walls,  and  are  not  tightly  distended,  so  that 
fluctuation  can  be  elicited  easily.    They  are  generally  unilateral 
and  do  not  cause  pain. 

2.  Cysts  of  the  corpus  luteum  are  not  larger  than  a  base-ball;  they 
have  thick  walls,  and  are  unilateral. 

3.  Simple  cysts  have  thin  walls  and  thin  fluid  contents,  and  are 
differentiated  clinically  from  follicular  cysts  only  by  their  greater 
size. 

4.  Multilocular  cysts   are   the   most   common   kind   of   ovarian 
tumors.     They  vary  in  size  from  very  small  to  enormous.     In  the 
beginning  such  a  tumor  is  round,  but  becomes  irregular  in  shape 
by  the  development  of  several  cysts  within  the  parent  cyst.    There- 
fore, the  surface  becomes  lobulated  and  in  some  cases  the  large 
and   small    daughter   cysts    can    be    palpated.     The   consistency 
varies  according  to  the  fluid  contents.     Hard  portions  are  apt  to 
be  found  in  the  walls  whore  there  has  been  no  cystic  degeneration. 
The   small  or  multilocular  tumors  are  fairly  movable;   the  larger 
ones   are   limited   in   motion   by   adhesions,   which  are  common, 
especially  to  the  omentum,  bowel,  and  abdominal  wall,  seldom  to 
the  uterus  or  other  pelvic  organs.     These  tumors  are  usually  uni- 
lateral and  have  a  well-marked  pedicle.    Ascites  is  generally  absent; 
when  present  it  is  in  small  amount. 

5.  Proliferating  papillary  cysts  are  seldom  larger  than  a  man's 
head.     They  are  not  often  perfectly  round  in  shape  and  have  an 
uneven,   lumpy  surface.     In   the  situations   where  the  papillary 
masses  occur  the  consistency  is  not  so  fluid  as  elsewhere.     The 
tumors  are  apt  to  affect  both  ovaries — double  tumor;  they  are  of 
intraligamentous  development,  at  least  on  one  side,  and  are  often 

21 


322  DIAGNOSIS  OF  DISEASES  OF  THE  OVARIES 

partially,  but  not  entirely,  in  the  broad  ligament.  When  the 
papillary  masses  have  pierced  the  wall  of  the  tumor  there  are 
metastases  in  different  parts  of  the  abdomen,  especially  in  Doug- 
las'  cul-de-sac.  Ascites  is  common. 

6.  Primary  carcinoma,  when  small,  retains  the  form  of  the  ovary; 
when  large,  the  tumor  has  a  surface  that  is  very  rough  because  of 
knobs  and  excrescences.     Small  tumors  are  hard,  large  ones  are 
cystic   because  of  degenerative  processes  inside.     The  pedicle  is 
for  the  most  part  short,  and  the  tumor  may  be  intraligamentous. 
The  tumors  are  generally  double  and  ascites  is  commonly  present. 
Early  edema  of  the  legs  is  to  be  looked  for  in  the  case  of  small 
tumors,  and  cachexia  in  the  late  stages.     Metastases  occur  early. 
Secondary  carcinoma  attacking  a  cyst  has  the  same  characteristics. 

7.  Dermoids  are  seldom  larger  than  a  man's  head  and  most  often 
between  a  hen's  egg  and  a  Florida  orange  in  size.     They  are  round 
and  oval  in  shape  and  are  seldom  double,   having    for  contents 
thick  fluid,  fat,  bone,  and  hair;  fluctuation  is  not  marked.     Some- 
times bone  may  be  felt  in  the  wall  of  the  cyst,  and  often  there  are 
portions  of  solid  tissue  in  dermoid  cysts.     These  cysts  are  of  slow 
development  and  occur  most  often  in  young  persons.     Adhesions 
are  common  and  occasionally  the  tumor  adheres  so  closely  to  the 
intestine  that  there  is  gas  in  the  tumor.     The  x-rays  may  show 
the  bone  in  a  tumor. 

8.  Teratomata  are  apt  to  be  the  size  of  a  man's  head  and  occur 
mostly  in  young  subjects.     Their  consistency  is  solid,  often  hard, 
and    they  may  contain  nodules  of    varying    consistency.     If  the 
tumor  is  malignant  there  are  metastases  and  ascites.     The  clinical 
diagnosis  can  seldom  be  made. 

9.  Fibroma  of  the  ovary  is  a  round  or  oval  tumor,  very  hard, 
with  smooth  surface  and  generally  unilateral.     It  may  be  as  large 
as  a  man's  head  and  ascites  is  usually  present.     Often  cystic  cavi- 
ties develop  in  such  tumors,  and  the  ascites  does  not  return  after 
the  tumor  has  been  removed.     Fibroma  can  not  be  distinguished 
clinically  from  fibrosarcoma. 

10.  Sarcoma  of  the  ovary  occurs  as  fibrosarcoma  (spindle-celled 
sarcoma)  and  as  round-celled  xarcoma.     The  former  is  generally 
double,  has  a  smooth  surface  and  a  hard  consistency,  and  ascites 
is   present.     It   is   benign,   and   no   metastases  are  formed.     The 
round-celled  sarcoma,  on  the  other  hand,  occurs  as  a  soft,  medullary 


PATHOLOGICAL  VARIETIES  OF  OVARIAN  TUMORS         323 

tumor  with  tolerably  smooth  surface.  It  is  generally  unilateral 
and  ascites  is  often  present  and  the  tumor  may  be  of  considerable 
size.  The  tumor  elements  perforate  the  surface  early  and  in- 
filtrate the  neighboring  organs,  especially  the  abdominal  cavity. 
ii.  Peri-  and  endothelioma  have  the  same  characteristics  as 
round-celled  sarcoma. 


CHAPTER  XVIII 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  FALLOPIAN  TUBES 

Anatomy  and  age  changes,  p.  324. 

Congenital  Anomalies,  p.  326:  Absence  of  the  tubes,  p.  326.  Accessory 
tubes  and  ostia,  p.  326.  Diverticula  from  the  tube,  p.  326.  Hernia  of  the 
tube,  p.  326.  Displacement  and  elongation  of  the  tube,  p.  326.  Cyst  of 
Morgagni,  p.  327. 

Salpingitis,  p.  327 :  Acute,  p.  327.  Chronic,  p.  329.  Gonorrheal,  p.  330. 
Tuberculous,  p.  330.  Actinomycotic,  p.  332.  Echinococcus  infection,  p. 
332.  Syphilitic,  p.  332. 

Retention  tumors  (Sactosalpinx),  p.  332.  Pyosalpinx,  p.  332.  Hydro- 
salpinx,  p.  333.  Hematosalpinx,  p.  334.  Diagnosis  of  Sactosalpinx,  p.  335. 

Differential  diagnosis  of  Appendicitis  and  Salpingitis,  p.  336. 

New  Growths,  p.  337 :  Polypus,  p.  337.  Papilloma,  p.  337.  Embryoma, 
p.  338.  Myoma  and  fibroma,  p.  338.  Fibromyxoma,  p.  338.  Carcinoma, 
p.  338.  Sarcoma,  p.  339.  Chorioepithelioma,  p.  339. 

ANATOMY  AND  AGE  CHANGES 

THE  Fallopian  tubes  are  developed  from  the  portion  of  Miiller's 
ducts  lying  above  the  round  ligaments,  and  as  they  come  from  the 
same  structures  as  the  uterus  and  vagina  they  arc  continuous  with 
these  organs  and  their  canals,  and  arc  parts  of  one  long  tube, 
branching,  when  it  reaches  the  uterine  horns,  into  two  tubes.  (See 
Fig.  71,  page  198.) 

Each  tube  occupies  the  free  border  of  the  broad  ligament.  It 
has  an  average  length  of  four  inches  (10  centimeters)  but  may 
vary;  sometimes  one  tube  is  longer  than  its  fellow.  The  inner 
third  of  the  tube  is  narrow  and  is  from  one-sixteenth  to  one-eighth 
inch  (2  to  4  millimeters)  in  diameter;  it  is  called  the  ivthmuK.  The 
outer  two-thirds  is  larger  in  diameter,  three-eighths  inch  (7  to  8 
millimeters),  is  called  the  ampulla,  and  ends  in  the  infundibulum, 
or  trumpet -shaped  depression,  in  the  center  of  which  is  the  oxtium 
abdominale  surrounded  by  the  fnnhritr,  or  fringes.  These  fringes 
are  extensions  of  the  reduplicated  mucous  membrane  lining  the 
tube  and  are  of  uneven  length.  Running  from  the  abdominal 

324 


ANATOMY  AND  AGE  CHANGES  325 

ostium  to  the  ovary  is  the  tubo-ovarian  ligament,  traversed  by  a 
furrow  so  that  it  appears  to  be  a  long  fimbria.  This  represents 
the  uppermost  portion  of  Miiller's  duct  that  has  been  opened  out, 
instead  of  remaining  as  a  closed  tube.  The  tube  is  convoluted, 
the  isthmus  is  directed  outward  and  slightly  upward;  while  the 
ampulla  arches  over  and  descends,  so  that  the  infundibulum  is 
directed  toward  the  ovary  and  the  fimbrise  are  in  contact  with  that 
gland.  (See  Fig.  116,  p.  285.) 

The  lumen  of  the  tube  varies  from  the  diameter  of  a  bristle  at 
the  isthmus  to  a  quarter  of  an  inch  (some  5  millimeters)  in  the 
ampulla.  It  is  lined  with  mucous  membrane,  and  covered  with 
columnar  ciliated  epithelium,  which  is  reduplicated  and  thrown 
into  longitudinal  folds.  These  folds  become  thicker  as  they  ap- 
proach the  infundibulum  and  on  the  abdominal  side  of  the  ostium 
are  continuous  with  the  fimbriac.  The  tube  is  composed  of  un- 
striped  muscle  fiber,  continuous  with  that  of  the  uterus,  and  ar- 
ranged in  an  outer  longitudinal  layer  and  an  inner  circular  layer. 
Outside  the  longitudinal  layer  is  loose  connective  tissue  between 
it  and  the  peritoneum,  which  covers  two-thirds  of  the  circumfer- 
ence of  the  tube  and  is  terminated  by  a  sharp  edge  at  the  ostium 
abdominale. 

The  function  of  the  tubes  is  to  carry  the  ova  to  the  uterus.  It 
has  been  shown  by  Hofmeier  and  Mandl  (J.  Whitridge  Williams, 
"Gynecology  and  Abdominal  Surgery,"  Kelly  and  Noble,  Vol.  II., 
p.  132)  that  there  is  a  current  of  fluid  from  the  peritoneum,  or 
secretion  from  the  tubal  mucosa,  promoted  by  the  cilia  of  the  tubal 
epithelial  cells,  from  the  abdominal  ostium  of  the  tube  to  the 
internal  os  of  the  uterus.  It  has  been  proved  by  experiments  on 
animals  and  a  few  observations  on  human  beings  that  a  few  hours 
after  coitus  spermatozoa  can  be  found  in  the  outer  portions  of  the 
tubes  and  even  on  the  ovaries,  so  that  it  would  appear  that  the 
spermatozoa  get  into  the  tubes  in  spite  of  the  current  against  them, 
and  that  the  tube  is  the  normal  place  of  impregnation  rather  than 
the  uterus.  Under  normal  conditions  the  fertilized  ovum  is  passed 
along  by  the  cilia  to  the  uterus  where  it  becomes  embedded  in  the 
uterine  mucosa.  Under  abnormal  conditions  it  is  arrested  in  the 
tube  and  a  tubal  pregnancy  results. 

At  the  menopause  the  Fallopian  tubes  atrophy,  becoming  shorter 
and  narrower  and  the  epithelial  elements  disappear,  so  that  in  the 


326  DISEASES  OF  THE  FALLOPIAN  TUBES 

old  woman  they  are  nothing  but  slender  cords,  often  having  no 
lumen.     (See  Fig.  119,  p.  289.) 

CONGENITAL  ANOMALIES 

Absence. — Complete  absence  of  both  tubes  is  exceedingly  rare 
and  occurs  only  in  connection  with  failure  or  rudimentary  develoj)- 
ment  of  the  uterus.  Absence  of  one  tube  is  found  in  cases  of  failure 
of  development  of  the  corresponding  uterine  horn.  Partial  de- 
velopment of  the  tube  is  more  comman  than  complete  absence,  the 
tube  being  represented  by  a  narrow,  impervious  cord,  or  a  portion 
of  the  tube  only  may  be  implicated,  and  the  isthmus  may  be  normal 
while  the  ampulla  is  undeveloped  or  atypical,  or  vice  versa.  The 
diagnosis  can  not  be  made  without  an  abdominal  operation. 

Accessory  tubes  have  been  described  not  infrequently.  Probably 
many  of  them  are  not  true  cases  of  extra  tubes  but  accessory  ostia, 
a  much  more  common  condition.  Three  reporters  at  least  have 
given  instances  of  true  double  tubes,  and  Nagel  (Veit's  "  Handbuch," 
Bd.  I.)  found  a  double  Miillerian  duct  in  a  human  embryo. 

Accessory  ampullae  communicate  with  the  main  lumen  of  the 
tube,  usually  entering  near  the  attachment  of  the  mesosalpinx. 
Each  has  its  own  infundibulum  and  fimbrise.  As  many  as  six 
accessory  ostia  have  been  reported;  one  or  two  are  not  uncommon. 

Diverticula  of  the  walls  of  the  tube  appearing  as  herniae  occur 
occasionally,  and,  like  the  supernumerary  ostia,  are  of  importance 
because  they  may  be  lodging-places  for  fertilized  ova,  and  thus  a 
cause  of  tubal  pregnancy.  This  anomaly,  as  also  the  preceding, 
can  not  be  diagnosed  except  at  operation. 

Hernia. — The  tube  is  found  sometimes  with  the  ovary  in  a  hernial 
sac.  Such  herniie  are  generally  of  the  inguinal  variety  and  uni- 
lateral. The  condition  is  not  susceptible  of  diagnosis  before  opera- 
tion. 

Displacement  and  elongation  of  the  tube  may  be  congenital  or 
acquired.  The  tube  is  displaced  to  a  greater  or  less  degree  with 
displacements  of  the  ovary  and  uterus,  and  also,  in  the  case  of  large 
ovarian  tumors  and  large  tumors  of  the  broad  ligament,  it  is  both 
displaced  and  elongated.  In  pregnancy  it  becomes  lengthened 
enormously  as  the  uterus  approaches  its  size  at  full  term  and  after 
labor  the  tube  involutes  with  the  uterus  to  regain  its  normal  size. 


SALPINGITIS  327 

Sometimes,  where  the  conditions  for  examination  are  most 
favorable,  i.e.,  very  thin  abdominal  walls  or  separation  of  the  recti, 
it  is  possible  to  palpate  an  elongated  Fallopian  tube  coursing  over 
a  tumor  or  at  the  side  of  a  pregnant  uterus.  Generally  the  diagnosis 
can  not  be  made. 

The  cyst  or  hydatid  of  Morgagni  is  a  small  cyst  rarely  larger  than 
a  pea,  attached  by  a  stalk  one  to  one  and  a  half  inches  (some  2  to  6 
centimeters)  long,  to  the  fimbriae  or  to  the  tube  itself.  It  is  en- 
tirely harmlesss  and  ha  no  clinical  importance. 


SALPINGITIS 

Salpingitis  is  the  chief  disease  of  the  Fallopian  tubes  of  interest 
to  the  practising  physician. 

The  classification  of  salpingitis  from  an  etiological  standpoint  is 
difficult  because  it  is  impossible  to  distinguish  the  different  sorts  of 
bacteria  that  serve  as  exciting  causes.  The  streptococcus  and  the 
gonococcus  are  the  two  most  important  microorganisms.  It  is 
probable  that  in  those  cases  where  the  pus  in  the  tubes  is  ster- 
ile the  inflammation  was  originally  of  streptococcic  origin  but 
that  the  organism  has  died  out.  These  organisms  are  transmitted 
to  the  tubes  through  the  uterus,  an  endometritis  being  an  almost 
invariable  precursor  of  a  salpingitis.  The  tubercle  bacillus  is  a  not 
infrequent  cause  of  salpingitis,  and  rare  causes  are  actinomycosis, 
echinococcus  disease,  and  syphilis.  Hemorrhagic  salpingitis  may 
accompany  the  exanthemata,  and  there  is  a  mild  catarrhal  form  of 
salpingitis  and  perisalpingitis  of  unknown  origin  that  occurs  as  a 
complication  of  uterine  tumors. 

It  is  possible  for  fluids  injected  into  the  uterus  to  pass  into  the 
tubes,  especially  when  the  tubes  have  been  hypertrophied  by 
pregnancy  and  when  the  normal  tonus  is  not  present,  and  thus  set 
up  a  salpingitis,  though  this  is  an  academic  affair.  The  lumen  of 
the  isthmus  of  the  tube  is  very  small  and  the  irritation  caused  by 
foreign  fluids  sets  up  a  contraction  of  the  circular  fibers  so  that  it  is 
seldom  that  fluid  can  be  made  to  pass  through. 

Salpingitis  may  be  divided  clinically  into  acute  and  chronic. 

Acute  Salpingitis. — Pathology. — In  the  case  of  catarrhal  salpingitis, 
in  the  early  stages  of  an  acute  attack  the  mucous  membrane  is 


328  DISEASES  OF  THE  FALLOPIAN  TUBES 

swollen  so  that  the  redundant  folds  fill  the  lumen  of  the  tube.  The 
muscular  and  peritoneal  coats  are  involved  to  a  greater  or  less 
degree  and  the  entire  tube  is  reddened:  the  tissues  are  edernatous 
and  soft.  According  to  the  character  of  the  infecting  agent  the 
inflammatory  process  extends  or  does  not  to  the  ovary  and  neigh- 
boring structures  of  the  peritoneum  through  the  ostium  abdom- 
inale.  Apparently  sometimes  the  swelling  of  the  mucosa  in  the 
tube  is  sufficient  to  close  the  ostium  and  the  disease  is  limited  to 
the  tube  itself.  In  the  tube  accumulates  a  certain  amount  of  serous 
fluid,  drainage  into  the  uterus  being  interfered  with  by  the  swelling 
of  the  mucosa  in  a  very  small  canal. 

In  the  case  of  purulent  salpingitis  all  the  processes  are  intensified. 
The  mucous  membrane  is  more  swollen  and  injected;  the  entire 
tube  is  much  enlarged  and  there  is  pus  in  its  canal.  The  peritoneal 
covering  of  the  tube  is  involved,  and,  either  by  direct  extension  of 
the  inflammation  through  the  wall  of  the  tube,  or  because  of  the 
action  of  the  pus  that  escapes  from  the  ostium  of  the  tube,  ad- 
hesions of  the  ampulla  to  surrounding  structures, — bowel,  omen- 
turn,  bladder,  or  uterus,  are  formed.  The  mesosalpinx  and  broad 
ligament  arc  infiltrated  so  that  they  have  a  board-like  feeling. 

Symptoms. — The  symptoms  of  acute  catarrhal  salpingitis  are  so 
slight  that  they  are  overshadowed  by  the  symptoms  of  the  co- 
existing endometritis.  (See  page  174.)  The  symptoms  of  acute 
purulent  salpingitis,  on  the  other  hand,  are  often  severe,  consisting 
of  abdominal  pain,  fever,  rapid  pulse,  uterine  hemorrhage,  dysuria 
and  painful  defecation,  and  purulent  vaginal  discharge.  Accord- 
ing to  the  amount  of  localized  peritonitis  are  the  symptoms  more 
urgent.  Where  the  infection  involves  the  ovary  and  a  tubo- 
ovarian  abscess  results  the  symptoms  and  signs  are  those  of  pelvic 
abscess.  (See  page  193.) 

Diagnosis. — The  history  is  that  of  endometritis  (see  page  174) 
and  preceding  infection.  In  the  catarrhal  form  palpation  by  the 
bimanual  touch  may  reveal  tenderness  of  the  tube,  but  this  is  a 
fine  point  in  diagnosis.  In  the  purulent  form,  not  only  tenderness 
but  thickening  of  the  tube  may  be  evident.  It  is  especially  to  be 
cautioned  that  the  utmost  gentleness  be  used  because  of  the  danger 
of  expressing  pus  from  the  ostium  of  the  tube  into  the  peritoneal 
cavity. 

Evidences  of  endometritis  are  also  present.     If  there  is  much 


SALPINGITIS  329 

distention  of  the  tube  in  the  subacute  stage  the  tube  may  be  made 
out  as  a  sausage-,  club-,  or  retort-shaped  body,  and  it  is  apt  to  be 
in  the  cul-de-sac  of  Douglas.  (See  Pyosalpinx.)  Acute  purulent 
salpingitis  is  a  very  common  affection  and  the  attempt  should  be 
made  to  diagnose  the  disease  early  in  its  course. 

Chronic  Salpingitis. — Pathology, — Chronic  salpingitis  results  from 
an  acute  salpingitis.  The  tube  is  usually  closely  adherent  to  the 
ovary  and  surrounding  structures;  it  is  apt  to  be  in  the  cul-de-sac 
of  Douglas;  it  shows  marked  convolutions  and  twists.  The  walls 
of  the  tube  are  generally  thickened  and  indurated.  Sometimes 
the  thickening  is  in  the  isthmus,  and  at  others  in  the  ampulla. 
Now  and  then  one  finds  nodules  the  size  of  a  small  pea  in  the  struc- 
ture of  the  wall  of  a  tube  (salpingitis  nodosa),  these  being  found 
generally  in  the  isthmus.  On  section  they  show  a  dense  fibro- 
muscular  structure  containing  glandlike  spaces,  which  sometimes 
represent  the  lumen  of  the  tube.  Tubes  containing  these  nodes  are 
apt  to  be  impervious.  The  condition  is  not  to  be  confused  with 
nodular  tuberculosis  of  the  tube. 

The  ostium  of  the  tube  is  commonly  closed  by  peritonitic  adhe- 
sions or  exudate  in  cases  of  chronic  purulent  salpingitis,  but  often 
on  separating  the  adhesions  it  will  be  found  that  the  fimbrise  are 
free  and  the  ostium  is  patent.  It  is  probable  that  these  are  the 
cases  in  which,  upon  the  subsidence  of  the  inflammation  and  the 
absorption  of  the  exudate  in  the  peritoneum,  the  ostia  become 
pervious  again.  In  many  cases,  especially  those  due  to  gonococcus 
infection,  the  fimbrise  are  found  adherent  and  there  is  true  occlusion 
of  the  ostium. 

In  the  case  of  chronic  salpingitis  infection  from  the  tube  may 
be  transmitted  to  the  ovary,  and  a  tubo-ovarian  cyst  or  tubo- 
ovarian  abscess  may  result,  or  the  process  may  be  limited  to  the 
tube,  salpingitis  proper. 

Symptoms  and  Diagnosis. — The  symptoms  are  pains  in  the  groins, 
a  sense  of  weight  in  the  pelvis,  exacerbations  of  fever,  irregular- 
ity of  menstruation,  dysmenorrhea,  and  vaginal  discharge.  The 
diagnosis  is  made  by  palpating  enlarged  tubes,  by  the  presence 
of  preceding  and  coincident  endometritis,  and  by  symptoms  of 
pain  and  fever  not  accounted  for  by  the  endometritis. 

Salpingitis  duo  to  the  streptococcus  is  less  apt  to  affect  both 
tubes  than  is  the  gonorrheal  variety. 


330  DISEASES  OF  THE  FALLOPIAN  TUBES 

Gonorrheal  Salpingitis. — As  a  rule  it  is  a  long  time,  months  or 
years,  before  the  gonocoeci  of  an  endometritis  reach  the  tubes, 
although  they  have  been  found  in  the  tubes  within  two  weeks 
after  the  initial  infection;  therefore  the  disease  is  generally  de- 
scribed as  being  subacute  or  chronic  from  the  start. 

The  disease  is  usually  bilateral  and  may  be  ushered  in  by  a  chill, 
fever,  and  local  tenderness  and  pain.  In  the  more  chronic  stages 
the  amount  of  tenderness  is  variable  and  may  be  wanting,  there 
is  generally  no  fever,  and  the  patient  may  be  in  fair  health 
except  for  anemia  and  debility;  but  during  the  menstrual 
periods  there  arc  dysmenorrhea,  local  tenderness,  irregularities 
of  menstruation,  and  increased  vaginal  discharge  as  troublesome 
symptoms.  Acute  attacks  of  inflammation  are  apt  to  occur  in 
the  history  of  chronic  gonorrheal  salpingitis  and  whenever  a 
drop  of  pus  escapes  into  the  peritoneal  cavity  there  is  inflam- 
matory reaction. 

As  previously  stated,  the  ostia  of  the  tubes  are  more  apt  to  be 
closed  by  gonorrheal  than  by  streptococcic  inflammation,  thus 
accounting  for  the  sterility  of  prostitutes. 

Diagnosis. — Unless  the  gonocoeci  can  be  found  in  the  discharges 
from  the  uterus  there  is  no  way  of  distinguishing  this  form  of 
salpingitis  from  any  other.  The  probabilities  may  point  in  this 
direction  from  a  history  of  gonococcus  infection,  from  the  occur- 
rence of  gonorrheal  joint  affections,  or  from  evidences  of  past 
inflammation  in  the  vaginal  or  inguinal  glands. 

Tuberculous  Salpingitis. — The  Fallopian  tube  is  the  most  frequent 
site  of  genital  tuberculosis  in  the  female.  Where  careful  routine 
microscopical  investigations  have  been  made  of  all  the  clinical 
material  furnished  by  the  operating-rooms  of  hospitals  it  has  been 
found  that  from  five  to  ten  per  cent  of  all  the  inflammatory  affec- 
tions of  the  tubes  are  tuberculous.  Without  painstaking  investiga- 
tions it  is  impossible  often  to  distinguish  tuberculous  from  simple 
salpingitis. 

The  disease  may  be  primary  in  the  tubes  (it  is  generally  bilateral) 
or  secondary  to  a  lesion  or  lesions  at  a  distance,  as  in  the  lungs,  or 
in  a  contiguous  organ,  such  as  a  tuberculous  ulcer  of  the  intestine. 
The  tubercle  bacillus  may  come  to  the  tube  from  the  vagina  by 
way  of  the  uterus,  or  from  the  blood  current.  The  infection  may 
be  limited  to  the  tubes,  or  both  uterus  and  tubes  are  involved. 


SALPINGITIS  331 

It  is  possible,  and  not  a  very  uncommon  happening,  for  the  gono- 
coccus  to  be  associated  with  the  tubercle  bacillus. 

Pathology. — Tuberculosis  of  the  tubes  appears  in  three  forms, 
miliary,  caseous,  and  fibrous.  The  appearances  of  the  tube  vary 
according  as  the  disease  began  in  the  mucous  membrane  lining 
its  cavity  or  in  the  peritoneal  coat.  The  tube  may  be  atrophied 
or  much  enlarged  and  tortuous  and  a  part  or  the  entire  tube  may 
be  affected.  Microscopically  tuberculous  nodules  are  found.  These 
consist  of  a  central  giant  cell  surrounded  by  epithelioid  cells  and 
an  outer  zone  of  small  round  cells.  Caseous  foci  are  common  and 
the  folds  of  the  mucosa  are  thickened  and  adherent.  The  lumen 
of  the  tube  may  be  closed  by  a  hyperplastic  process  affecting  the 
mucosa  just  as  ir  the  swelling  which  accompanies  infections  by 


FIG.  136. — Tuberculous  Salpingitis.     (Dudley.) 

other  organisms.  The  disease  generally  is  progressive,  but  may 
be  arrested,  the  tube  being  represented  in  such  cases  by  a  thin, 
impervious,  fibrous  cord.  If  the  disease  progresses  one  expects  to 
find  tuberculosis  of  the  peritoneum. 

Diagnosis. — Tuberculous  salpingitis  is  seldom  seen  in  an  early 
stage  when  the  diagnosis  can  be  only  that  of  salpingitis.  A 
tuberculous  history  or  tuberculosis  elsewhere  in  the  body  leads  one 
to  suspect  the  etiological  significance  of  a  salpingitis  and  some- 
times in  the  later  stages  fluid  in  the  peritoneum  calls  attention  to 
tuberculosis.  Pyrcxia,  recurring  every  evening  and  disappearing 


332  DISEASES  OF  THE   FALLOPIAN  TUBES 

every  morning,  loss  of  weight  and  strength,  rapid  pulse,  sweating, 
particularly  at  night,  are  symptoms  of  tuberculosis. 

Actinomycotic  salpingitis  is  secondary  to  actinomycosis  elsewhere, 
besides  being  very  rare.  The  tubes  are  converted  into  abscesses 
in  which  the  characteristic  yellow  or  brownish-black,  sago-like 
granules  are  readily  recognized.  Under  the  microscope  the  acti- 
nomyces  is  recognized  in  the  characteristic  granulation  tissue. 

Echinococcus  infection  is  extremely  rare  also,  and  is  secondary  to 
hydatid  disease  in  the  broad  ligament  or  elsewhere  in  the  pelvis. 
Sometimes,  but  not  always,  pelvic  hydatids  are  secondary  to 
hydatid  disease  of  the  liver  or  other  abdominal  organ.  Cases 
have  been  reported  of  tubes  enormously  distended  by  hydatids. 
The  diagnosis  would  rest  on  the  discovery  of  the  disease  in  some 
neighboring  organ  or  the  passage  of  cysts  from  the  vagina,  rectum, 
or  bladder. 

Syphilitic  salpingitis  must  be  regarded  as  a  very  rare  disease. 
It  has  been  found  in  the  newT-born  and  extremely  rarely  in  the 
adult.  The  tubes  contain  miliary  gummata  in  their  walls,  and  the 
folds  of  the  mucosa  are  adherent.  In  one  case  in  an  adult,  gummata 
the  size  of  hazelnuts  were  found.  The  diagnosis  is  made  probable 
by  finding  evidences  of  syphilis  in  other  situations  in  the  body, 
by  the  history  of  syphilis,  and  by  the  presence  of  an  enlarged  tube. 


RETENTION  TUMORS    OF   THE    TUBE,  OR    SACTOSALPINX 

Pyosalpinx  is  a  Fallopian  tube  distended  with  pus.  The  tube 
varies  in  size  and  shape.  With  moderate  distention  it  is  club- 
shaped,  having  a  number  of  convolutions;  with  more  distention  it 
is  retort-shaped  with  the  stem  of  the  retort  at  the  uterine  horn; 
here  the  convolutions  are  more  or  less  eliminated.  With  extreme 
distention  the  tube  becomes  an  oval  sac.  These  large  tubes  are 
uncommon.  The  largest  ones  I  remember  having  met  were  in  the 
case  of  a  woman  twenty-three  years  old,  upon  whom  Dr.  Clement 
Cleveland  operated  with  my  assistance  January  20,  1890.  The 
patient  had  been  married  one  year  and  had  not  been  pregnant. 
She  had  very  few  symptoms.  The  right  tube  measured  six  inches 
in  length,  and  three  inches  in  diameter  at  its  outer  end,  and  one 
and  three-fourths  inches  at  its  inner  end.  Three  inches  of  the 


RETENTION  TUMORS  OF  THE  TUBE 


333 


isthmian  end  of  the  tube  were  not  enlarged.  This  tube  had  com- 
paratively few  adhesions  about  it.  The  left  tube  measured  four 
inches  in  length,  and  three  inches  in  diameter,  and  the  surrounding 
adhesions  were  dense.  Each  was  ovoid  in  shape  and  showed  no 
convolutions. 

As  a  rule  a  pus  tube  is  surrounded  by  adhesions,  because  its 
peritoneal  surface  is  enveloped  in  an  inflammatory  membrane. 
The  pus  is  sterile  in  over  half  of  all  cases.  This  fact  is  explained  by 
the  dying  out  of  the  microorganisms  which  have  caused  the  inflam- 
mation and  are  always  to  be  found  in  the  acute  and  subacute  cases. 
The  walls  of  a  pyosalpinx  are  generally  thick,  but  they  may  be  thin. 


FIG.  137. — Pyosalpinx. 

Iii  the  older  cases  the  epithelial  lining  of  the  tube  has  been  replaced 
by  granulation  tissue.  Rupture  into  the  peritoneal  cavity  is  an 
accident  which  has  occurred,  although  not  very  commonly.  C.  W. 
Bouncy  (Surgery,  Gynecology,  and  Obstetrics,  Nov.,  1909,  p.  542) 
collected  forty-five  cases,  including  the  cases  from  the  literature 
and  a  case  of  his  own.  In  most  instances  there  was  no  assignable 
cause  for  the  rupture.  Whenever  infection  has  set  up  an  abscess 
of  the  ovary  as  well  as  a  pyosalpinx  the  condition  is  known  as  a 
tubo-ovarian  abscess.  This  has  been  described  under  Pelvic  Abscess. 
(See  Chapter  XII,  page  193.) 

The  diagnosis  of  pyosalpinx  will  be  considered  with  the  diag- 
nosis of  hyclrosalpinx  and  hematosalpinx. 

Hydrosalpinx  is  an  accumulation  of  serous  fluid  in  the  tube.     It 


334 


DISEASES  OF  THE  FALLOPIAN  TUBES 


presupposes  complete  closure  of  the  ostium  abdominale,  but  not 
necessarily  the  lumen  of  the  isthmus  of  the  tube,  and  is  the  result 
of  a  preexisting  salpingitis.  In  intermittent  hydrosalpinx  there  is 
a  temporary  obstruction  to  the  uterine  outlet  of  the  tube  caused 
by  kinks  in  the  isthmus,  that  is,  a  mechanical  stenosis  exists.  In 
such  cases  there  is  a  periodic  discharge  of  watery  fluid  through  the 
uterus.  The  shapes  of  tubes,  the  seat  of  hydrosalpinx,  are  the  same 
as  those  of  pyosalpinx,  but  the  walls  are  thinner  and  on  micro- 
scopic examination  are  seen  to  be  practically  normal,  except  in 
the  case  of  follicular  hydrosalpinx ,  in  which  there  are  evidences 


/VormaL  inner  third 
of  tube 


FIG.  138. — Hydrosalpinx,  Two-thirds  Actual  Size.     (Author's  Case). 

of  endosalpingitis.  Hydrosalpinx  is  seldom  larger  than  a  Bartlett 
pear,  although  cases  have  been  reported  the  size  of  a  child's  head. 
The  ampulla  of  the  tube  is  dilated  with  fluid  more  often  than  the 
isthmus.  If  an  ovarian  cyst  connects  with  a  distended  tube  by 
an  adventitious  opening  not  the  ostium  abdominale,  the  condition 
is  known  as  a  tubo-ovarian  cyst.  These  cysts  arc  by  no  means 
uncommon,  and  can  not  be  distinguished  clinically  from  hydrosal- 
pinx, except  in  those  rare  cases  of  hydro  salpinx  in  which  the  normal 
ovary  can  be  palpated  by  bimanual  touch. 

Hematosalpinx  is  a  Fallopian  tube  distended  with  fluid  blood. 
Hemorrhage  occurring  into  a  hydrosalpinx  forms  a  hematosalpinx. 
It  is  now  believed  that  a  majority  of  cases  of  hematosalpinx  are 


RETENTION  TUMORS  OF  THE  TUBE  335 

the  result  of  tubal  pregnancy  and  incomplete  abortion.  (See 
Tubal  Pregnancy.)  Hematosalpinx  presupposes  closure  of  the 
ends  of  the  tube  just  as  in  the  case  of  pyosalpinx  and  hydrosalpinx. 
Hemorrhage  into  the  tube  may  take  place  as  a  result  of  torsion  of 
the  tube  and  it  occurs  as  a  complication  of  fibroids  of  the  uterus. 
It  is  found  also  in  cases  of  imperforate  hymen  with  accumulation 
of  menstrual  blood  in  the  uterus  (hematometra). 

Hematosalpinx  resembles  hydrosalpinx  as  to  size  and  shape, 
but  is  of  a  dark  reddish-brown  color.     The  walls  are  thick,  but 


of  Tube 


FIG.  139. — Hematosalpinx,  Actual  Size,   Caused  by  Acute  Torsion  of    Right 
Tube.    Twist  of  Two  Turns  to  the  Right  at  the  Isthmus.    (Author's  Case). 

friable,  and  covered  by  adhesions.  On  microscopic  examination 
it  is  seen  that  the  mucosa  is  degenerated  and  destroyed,  the  muscu- 
lar tissue  is  swollen  and  infiltrated,  while  the  peritoneal  coat  shows 
thrombosed  vessels  and  deposits  of  blood  pigment. 

DIAGNOSIS   OF  SACTOSALPINX 

The  diagnosis  of  pro-,  hydro-,  and  hematosalpinx  rests  on  the 
determination  by  palpation  of  a  tumor  of  the  shape  of  a  dilated 
tube  connected  with,  but  not  a  part  of  the  uterus.  If  the  normal 
ovary  can  be  distinguished  separate  from  the  tumor  so  much  the 
better.  In  the  cases  where  the  tube  is  not  very  large  the  charac- 
teristic shape — club-shaped,  pyriform,  or  retort-shaped — can  be 


336  DISEASES  OF  THE  FALLOPAN  TUBES 

made  out  with  clearness.  Also  in  these  cases  the  isthmus  of  the 
tube  connecting  the  tumor  with  the  uterine  horn  may  be  palpated. 
With  the  larger  tubes  no  characteristic  shape  can  be  learned  by 
palpation.  If  both  tubes  are  enlarged  it  is  a  strong  diagnostic 
point  in  favor  of  retention  tumors  because  these  are  generally 
bilateral. 

Pelvic  peritonitis  with  adhesions  is  an  almost  universal  accom- 
paniment of  these  tumors,  therefore  they  are  more  or  less  fixed. 
There  is  no  means  of  knowing  previous  to  operation  the  contents 
of  a  dilated  tube,  whether  pus,  serum,  or  blood.  Aspiration  is 
not  justifiable  because  by  puncturing  the  tumor  its  contents  may 
contaminate  the  peritoneum,  thus  complicating  needlessly  an 
operation  for  removal,  which  is  indicated  in  all  cases. 

The  diagnosis  of  rupture  of  a  retention  tumor  is  the  same  as 
that  of  rupture  of  an  ovarian  tumor  (see  page  319). 

Torsion  to  the  point  of  strangulation  is  evidenced  by  acute 
stabbing  abdominal  pain,  vomiting,  and  the  signs  of  a  tender 
tumor  in  the  situation  of  the  tube.  Torsion  without  stran- 
gulation has  been  reported  in  only  three  cases.  Storer  in  1906 
(M.  Storer,  Boston  Med.  and  Surg.  Jour.,  March  15,  1906,  page 
285)  reported  a  case  of  bilateral  torsion  and  collected  sixty-two 
cases  of  torsion  of  the  tube  in  the  literature  since  Bland-Sutton 
first  called  attention  to  the  condition  in  1890. 

DIFFERENTIAL  DIAGNOSIS  BETWEEN  SALPINGITIS  AND  APPENDICITIS 

Right-sided  salpingitis  is  often  mistaken  for  appendicitis.  It 
should  be  remembered  that  the  two  affections  may  co-exist, 
and  in  this  case  which  was  in  the  beginning  the  exciting  cause  and 
which  is  the  chief  factor  at  the  present  time,  are  shown  by  the  clinical 
history  of  the  onset  of  the  attack.  Acute  salpingitis  is  usually 
preceded  by  endometritis,  by  a  vaginal  discharge,  and  by  menstrual 
disturbances,  often  by  dysmenorrhea.  In  the  case  of  appendicitis 
there  is  a  history  of  digestive  disturbances,  of  irregularity  of  the 
bowels,  or  of  previous  attacks  of  pain  in  the  right  side.  Rovsing 
has  made  use  of  a  method  of  reproducing  the  pain  of  appendicitis 
that  is  of  value  sometimes  in  the  differential  diagnosis.  lie  strokes 
the  descending  colon  from  below  upward,  and  the  transverse  colon 
from  left  to  right,  thus  forcing  gas  back  into  the  cecum  and  appen- 


NEW  GROWTHS  337 

dix,  distending  those  structures  and  reproducing  a  pain  similar  to 
that  from  which  the  patient  has  suffered. 

In  salpingitis  the  pain  is  more  steady,  less  intense,  and  radiates 
into  the  pelvis,  while  in  appendicitis  it  is  colicky  and  more  general. 

Dr.  Robert  T.  Morris  (Jour.  Amer.  Med.  Asso.,  January  25,  1908, 
Vol.  L.,  page  278)  has  directed  attention  to  two  points  of  tenderness, 
called  Morns'  points,  which  he  considers  of  great  assistance  in 
distinguishing  between  chronic  salpingitis  and  chronic  appen- 
dicitis. One  point  is  situated  one  and  a  half  inches  from  the 
umbilicus  on  a  line  drawn  from  the  umbilicus  to  one  anterior 
superior  spinous  process  of  the  ilium,  and  the  other  point  is  in  a 
similar  situation  on  the  opposite  side.  These  points  are  approxi- 
mately over  the  lumbar  lymph  glands  which  receive  the  lymph  ves- 
sels from  the  Fallopian  tubes,  ovaries,  uterus,  and  broad  ligaments, 
and  also  from  the  appendix.  McBurney's  point  is  on  this  same 
line  on  the  right  side  one  and  a  half  inches  from  the  spinous  process. 
The  right  Morris'  point  is  tender  on  pressure  in  the  case  of  chronic 
appendicitis  not  involving  the  Fallopian  tube,  sometimes  even 
when  McBurney's  point  is  not  tender.  In  the  case  of  salpingitis 
either  unilateral  or  bilateral  both  Morris'  points  are  tender.  Several 
physicians  have  reported  satisfactory  results  from  the  use  of  this 
means  of  diagnosis  and  it  may  be  regarded  as  an  accessory  to  other 
methods  of  diagnosis  in  chronic  cases. 


NEW  GROWTHS 

Primary  new  growths  of  the  Fallopian  tubes  are  relatively  rare. 
They  originate  in  the  mucosa,  or  in  the  walls  of  the  tube,  and  are 
benign  or  malignant.  The  benign  growths  are,  polypus,  papilloma, 
embryoma,  myoma  and  fibroma,  and  fibromyxoma.  The  malig- 
nant growths  are  carcinoma,  sarcoma,  and  chorioepithelioma. 

Polypus  of  the  mucosa  is  rare.  It  consists  of  simple  inflammatory 
thickening  of  the  mucous  membrane  or  a  polypus  similar  to  a 
uterine  polypus  originating  from  placental  tissue  left  attached  to 
the  tubal  wall  by  a  tubal  pregnancy. 

Papilloma  is  thought  to  be  a  result  of  an  old  salpingitis  rather 
than  a  neoplasm  proper.  K.  Hurdon  ("Gyneeology  and  Abdominal 

Surgery, "  Kelly  and  Noble,  Vol.  I,  p.  174)  has  collected  fourteen 
"22 


33S  DISEASES  OF  THE  FALLOPIAN  TUBES 

cases  from  the  literature.  According  to  this  authority  the  disease 
consists  of  a  cauliflower  papillary  mass  which  originates  in  the 
mucous  lining  of  the  tube  and  distends  the  lumen  without  invading 
the  wall.  "Small  peritoneal  papillomata  may  develop,  but  metas- 
tases  do  not  occur.  Like  the  ovarian  papillomata  the  tubal 
growths  often  produce  an  ascites.  If,  however,  the  abdominal 
ostium  is  closed,  there  is  no  ascites  and  the  fluid  is  either  retained 
in  the  tube  or  is  discharged  through  the  uterus  (hydrops  tubse 
profluens)."  Papilloma  of  the  tube  is  generally  unilateral. 

Embryoma. — There  have  been  at  least  four  authentic  cases  of 
dermoid  tumor  of  the  tube  reported  in  the  literature,  occurring 
in  patients  between  the  ages  of  twenty-five  and  forty-eight.  One 
of  the  cases  was  an  oval  tumor  the  size  of  a  hen's  egg,  which  on 
section  showed  a  tumor  mass  free  in  the  tubal  canal  and  having 
only  a  superficial  attachment  to  the  mucosa. 

Myoma  and  fibroma,  occurring  as  small  nodules  in  the  tubal  walls, 
are  not  to  be  confused  with  the  salpingitis  nodosa  of  gonorrhea 
or  with  the  nodules  occurring  in  tuberculosis  of  the  tubes.  Bland- 
Sutton  says  ("Surgical  Diseases  of  the  Ovaries  and  Fallopian 
Tubes,"  page  286):  "I  have  satisfied  myself  that  when  there  is  a 
general  myomatous  enlargement  of  the  uterus,  the  muscle  tissue  of 
the  tubes  also  participates  in  the  change,  becoming  thick  and  hard." 

A  true  fibromyomatous  nodule  similar  in  every  respect  to  uterine 
fibromyomata  and  the  size  of  a  walnut  has  been  described  as 
occurring  in  the  tube.  Even  larger  tumors  have  been  reported. 
They  are  extremely  rare. 

Fibromyxoma. — One  case  of  fibromyxoma  of  the  tube  has  been 
reported  in  the  literature,  the  tumor  being  about  the  size  of  a  fist. 

Carcinoma. — Hurdon  refers  to  seventy  cases  of  primary  car- 
cinoma <of  the  tube  in  the  literature.  The  disease  usually  affects 
one  tube,  though  it  may  be  bilateral.  It  occurs  most  often  in 
women  who  are  between  forty  and  sixty  years  of  age  and  chronic 
salpingitis  is  thought  to  stand  in  an  etiologic  relation  to  the  disease. 
It  originates  in  the  epithelial  covering  of  the  mucosa  and  develops 
in  the  form  of  a  papillary  tumor.  The  diseased  tube  is  converted 
into  a  large  cylindrical  pear-shaped  tumor,  which  may  reach  the 
size  of  a  child's  head,  but  is  usually  about  the  size  and  shape  of  a 
retention  tumor  of  the  tube.  The  disease  may  advance  by  direct 
extension  to  the  surrounding  structures  or  by  metastases. 


NEW  GROWTHS  339 

Sarcoma. — There  are  only  five  cases  of  this  disease  in  the  lit- 
erature, two  round-cell,  one  spindle-cell,  and  one  myxosarcoma. 
The  tumor  arises  in  the  connective  tissue  of  the  mucous  membrane 
or  tube  wall  and  presents  a  papillary  or  polypoid  character. 

Chorioepithelioma  of  the  tube,  as  a  sequence  of  tubal  gestation, 
seems  to  be  relatively  as  frequent  as  chorioepithelioma  of  the  ute- 
rus following  uterine  pregnancy.  Hurdon  notes  eleven  cases  that 
have  been  reported.  In  the  place  of  the  tube  there  is  a  large  sac 
with  thin,  friable  walls,  which  encloses  a  soft,  spongy  structure 
resembling  placenta,  and  masses  of  bloody,  fibrinous  material. 
Histologically  the  findings  are  the  same  as  in  chorioepithelioma 
of  the  uterus. 

The  diagnosis  of  neoplasms  of  the  tube  can  be  only  a  probability. 
Fortunately  they  are  very  rare.  After  diagnosing  a  tumor  of  the 
tube  by  palpation,  the  possibility  of  its  being  a  neoplasm  should 
be  borne  in  mind. 

Tubal  pregnancy  will  be  considered  in  the  next  chapter  under 
Extra-uterine  Pregnancy. 


CHAPTER  XIX 

THE  DIAGNOSIS  OF  EXTRA-UTERINE  PREGNANCY 

Tubal  pregnancy,  p.  341:  Frequency,  p.  341.  Etiology,  p.  341.  Pa- 
thology, p.  343.  Uterine  dccidua,  p.  344.  Fate  of  the  fetus,  p.  344.  Dis- 
eases of  the  ovum,  p.  345. 

Ovarian  pregnancy,  p.  34.3. 

Symptoms  and  signs  of  extra-uterine  pregnancy,  p.  346:  Pelvic  hemat- 
ocele,  p.  347.  Multiple,  combined,  and  repeated  tubal  pregnancies,  p.  348. 

Diagnosis,  p.  348 :  Early  extra-uterine  pregnancy,  p.  348.  Late  extra- 
uterine  pregnancy,  p.  3.30. 

Differential  diagnosis,  p.  3.51  :  Early  extra-uterine  pregnancy  before 
rupture,  p.  3,51.  Early  extra-uterine  pregnancy  after  rupture,  p.  352.  Late 
extra-uterine  pregnancy,  p.  3,53. 

DEFINITIONS 

BY  extra-uterine  pregnancy  we  understand  the  development 
of  a  fertilized  ovum  at  some  point  between  the  Graafian  follicle 
in  which  it  originates  and  the  uterus. 

The  fertilized  ovum  may  develop  on  the  ovary  itself,  ovarian 
pregnancy,  on  the  fimbria  ovarica,  one  of  the  fringes  at  the  ostium 
abdominale  of  the  Fallopian  tube  that  extends  from  the  ostium 
to  the  ovary,  so  called  abdominal  pregnancy,  or  in  the  tube,  tubal 
pregnancy. 

It  is  possible,  and  cases  have  been  reported,  of  a  fertile  ovum 
developing  in  a  tubo-ovarian  cyst,  the  fetal  sac  being  made  up 
partly  of  tubal  and  partly  of  ovarian  tissue.  Such  cases  are  spoken 
of  as  being  tubo-ovarian  pregnancies.  When  a  primary  tubal 
(ampullar)  pregnancy  has  grown  in  its  development  into  the  abdom- 
inal cavity  it  is  called  a  tubo-abdominal  pregnancy,  and  when,  at 
the  opposite  end  of  the  tube,  a  pregnancy  beginning  in  the  uterine 
end  of  the  isthmus  (interstitial  pregnancy)  develops  into  the  uterus 
it  is  referred  to  as  tubo-uterine  pregnancy. 

True  abdominal  pregnancy  does  not  exist,  the  cases  reported 
as  such  being  those  in  which  the  growth  of  the  fertilized  ovum 

340 


TUBAL  PREGNANCY 


341 


began  on  ovarian  or  tubal  structure  and  the  subsequent  develop- 
ment was  in  the  abdominal  cavity. 


TUBAL  PREGNANCY 

A  vast  majority  of  extra-uterine  pregnancies  are  tubal,  and  of 
these  the  ampullar  form  is  probably  the  most  common,  though 
some  authors  assert  that  the  isthmial  variety  has  the  precedence. 
The  interstitial  variety  is  the  rarest. 

Frequency. — It  would  appear  that  extra-uterine  pregnancy  is 
more  frequent  than  formerly,  but  whether  this  is  really  so  or  seems 


FIG.  140. — Early    Ampullar    Extra-uterine    Pregnancy.     Tubal    Abortion. 
Natural  Size.     (Kelly.) 

to  be  so  because  of  better  diagnosis  and  the  more  common  practice 
of  opening  the  abdomen,  is  not  plain.  In  1876  Parry  was  able 
to  collect  only  500  cases  from  the  literature;  to-day  the  literature 
teems  with  them.  One  prominent  gynecologist  in  this  country 
has  reported  recently  having  seen  as  many  as  300  cases  of  extra- 
uterine  pregnancy,  another  200,  and  a  third  has  operated  on  154 
cases.  Still  another  operator  says  that  operations  for  extra-uterine 
pregnancy  form  about  four  per  cent  of  all  his  abdominal  oper- 
ations, and  in  my  own  experience  such  operations  have  been  nearly 
five  per  cent  of  all  my  celiotomies. 
Etiology. — As  to  the  causation  of  tubal  pregnancy  we  are  still 


342 


EXTRA-UTERINE  PREGNANCY 


in  the  dark.  Dr.  J.  Whit  ridge  Williams  ("Extra- uterine  Preg- 
nancy/' Kelly  and  Noble,  "Gynecology  and  Abdominal  Surgery," 
Vol.  II.,  page  137),  to  whom  I  am  indebted  for  much  of  the  matter 
in  this  chapter,  after  reviewing  at  length  the  different  theories 
which  have  been  advanced  to  explain  its  occurrence,  says  of 
etiology:  "In  many  instances  the  arrest  of  an  ovum  in  a  crypt 
resulting  from  follicular  salpingitis,  or  in  a  diverticulum  from 
the  lumen  of  the  tube,  may  afford  a  satisfactory  explanation, 


r 


enlared 


FIG.  141. — Same  Case  as  Fig.  140.     The  Mole  and  the  Fetus  Have  Been  Re- 
moved from  the  Tube.     (Kelly.) 

though  in  a  certain  proportion  of  cases  even  the  most  careful 
history  of  the  patient  and  thorough  microscopic  examination 
of  the  specimen  will  fail  to  reveal  a  tangible  cause  for  the  condition." 
Any  woman  during  the  childbearing  age  may  have  extra-uterine 
pregnancy.  It  is  more  often  observed  in  women  who  have  been 
previously  sterile  or  when  there  has  been  a  long  interval  since 
the  last  pregnancy. 


TUBAL  PREGNANCY 


343 


Pathology. — It  appears  that  the  ovum  is  embedded  and  the 
placenta  is  formed  in  the  tube  exactly  as  in  the  uterus.  The  tube 
wall  is  invaded  by  the  fetal  elements,  its  structures  become  degen- 
erated and  in  part  converted  into  fibrin  so  that  they  offer  com- 
paratively little  resistance  to  the  developing  fetal  cells.  Shortly 
the  latter  are  found  just  under  the  peritoneum.  In  a  majority 
of  cases  early  rupture  of  the  tube  is  due  to  the  erosion  of  a  large 
blood-vessel  with  consequent  hemorrhage  and  a  giving  way  of  the 
thin  peritoneum. 

Tubal  pregnancy  may  terminate  by  abortion  into  the  lumen 


FIG.  142. — Pelvic  Hematocele. 

of  the  tube,  the  most  frequent  issue;  by  rupture  into  the  peritoneal 
cavity,  both  of  these  taking  place  during  the  first  few  weeks  of 
pregnancy;  or  by  development  even  to  term.  Rupture  is  more 
common  in  pregnancy  in  the  isthmus,  and  abortion  hi  ampullar 
pregnancy. 

As  far  as  the  results  go  it  makes  little  difference  whether  early 
rupture  takes  place?  through  the  capsular  membrane  into  the 
lumen  of  the  tube  or  through  the  wall  of  the  tube.  There  is  a 
hemorrhage  in  cither  case.  The  ovum  with  its  membranes  is  (1) 


344  EXTRA-UTERINE  PREGNANCY 

separated  completely  from  its  bed  and  is  expelled  into  the  lumen 
of  the  tube  and  perhaps  through  the  ostium,  or  (2)  is  expelled 
through  the  tubal  wall  directly  into  the  peritoneal  cavity  or,  (3) 
the  separation  is  partial,  the  ovum  remains,  and  the  hemorrhage 
continues.  The  last,  incomplete  abortions,  are  the  most  frequent. 
When  the  ovum  and  its  envelopes  are  extruded  at  once  through 
the  ostium  abdominale  the  hemorrhage  may  cease;  when,  on  the 
other  hand,  the  separation  of  the  ovum  from  the  tubal  wall  is 
only  partial,  the  ovum  may  increase  in  size  because  of  infiltration 
with  blood,  and  a  tubal  mole  is  formed.  Under  such  conditions  the 
hemorrhage  continues  as  long  as  the  mole  remains  in  the  tube 
and  the  blood  trickles  from  the  ostium  and  forms  a  pelvic  he- 
matocele  instead  of  free  hemorrhage  into  the  peritoneal  cavity  as 
in  the  case  of  complete  abortion  or  tubal  rupture. 

Tubal  rupture  occurs  more  frequently  in  isthmial  and  interstitial 
pregnancy  than  in  ampullar  pregnancy.  In  interstitial  pregnancy 
rupture  may  not  occur  until  as  late  as  the  fourth  month,  whereas 
in  isthmial  pregnancy  rupture  generally  occurs  within  the  first 
few  weeks  of  pregnancy,  not  infrequently  before  the  patient  is 
conscious  that  she  is  pregnant. 

Rupture  occurs  near  the  placental  site  and  is  either  into  the 
peritoneal  cavity  or  between  the  folds  of  the  broad  ligament. 

Uterine  Decidua. — A  decidua,  very  similar  in  structure  to  the 
decidua  of  uterine  pregnancy,  is  formed  in  the  uterus  coincident 
with  the  development  of  the  ovum  in  the  tube,  and  it  is  cast  off 
soon  after  the  death  of  the  fetus  either  in  small  pieces,  or,  rarely, 
as  a  complete  triangular  cast  of  the  uterine  cavity.  (See  Fig.  143.) 
Hemorrhage  from  the  uterus  is  apt  to  occur  when  the  decidua  comes 
away,  but  the  membrane  may  be  passed  without  the  patient's 
knowledge.  If  portions  can  be  obtained  for  microscopic  examina- 
tion, either  from  discharges  or  by  curetting  the  uterus,  they  furnish 
a  valuable  diagnostic  sign. 

Fate  of  the  Fetus. — The  extruded  ovum  is  always  killed  and  is 
absorbed  by  the  peritoneum  unless  it  is  advanced  beyond  the 
third  month.  It  is  highly  improbable,  as  thought  formerly,  that 
the  placenta  can  be  attached  to  other  structures  in  the  abdominal 
cavity,  at  this  time.  The  facts  go  to  show  that  attachment  is 
primary  either  on  the  ovary  or  tube  and  that  any  other  adhesions 
are  due  to  the  later  stages  of  the  development  of  the  fetus  and 


OVARIAN  PREGNANCY  345 

placenta.  If  the  rupture  is  between  the  folds  of  the  broad  ligament, 
a  rare  happening,  the  fetus  dies  and  a  hematoma  of  the  broad 
ligament  is  formed.  Exceptionally  when  the  placenta  is  not 
injured  pregnancy  may  continue  in  the  broad  ligament  or  the 
broad  ligament  sac  may  rup- 
ture into  the  peritoneal  cavity 
and  a  secondary  abdominal  preg- 
nancy results. 

If  the  fetus  has  developed 
beyond  the  third  month  it  may 
be  mummified,  consisting  of  an 
absorption  of  the  fluid  portions 
so  that  there  is  nothing  left  but 
shriveled  skin  holding  together 
the  bones  of  the  skeleton,  or, 
rarely,  it  may  form  a  lithope- 
dion,  a  mummified  fetus  in 
which  lime  salts  have  been  de- 
posited. Sometimes  the  dead 
fetus  and  its  membranes  sup- 
purate and  an  abscess  is  formed  FlG  143.-UteriiTe  Decidua  from  a 
and  very  exceptionally  this  fetus  Case  of  Extra-Uterine  Pregnancy, 
becomes  converted  into  adipo-  (Zweife1-) 
cere,  a  sort  of  ammoniacal  soap  found  occasionally  in  dead  bodies. 

Diseases  of  the  Ovum. — The  occurrence  of  tubal  mole  has  been 
referred  to  already.  (See  page  344.)  Hydalidiform  mole  has  been 
found  in  the  tube  and  differs  in  no  respect  from  hydatidiform 
mole  occurring  in  the  uterus.  In  this  situation  it  is  followed  by 
chorwepithelioma  just  as  in  the  uterus. 

In  most  cases  of  advanced  tubal  pregnancy  there  is  a  diminution 
in  the  amount  of  liquor  amnii,  but  hydramnios  has  been  observed. 
There  are  two  cases  on  record  of  patients  who  had  eclampsia 
during  false  labor. 

OVARIAN  PREGNANCY 

J.  Whitridge  Williams  has  collected  from  the  literature  thirteen 
positive'  cases  of  ovarian  pregnancy,  in  eleven  of  which  the  preg- 
nancy had  not  progressed  beyond  the  fourth  month.  In  addition 


:UG 


EXTRA-UTERINE  PREGNANCY 


ho  classed  as  highly  probable  or  probable  ovarian  pregnancy, 
twenty-two  other  cases.  In  eleven  of  these  thirty-five  cases 
pregnancy  had  progressed  to  full  term,  so  that  the  inference  is 
that  the  ovary  can  accommodate  itself  more  readily  than  the 
tube  to  the  growing  fetus.  Early  rupture  is  the  rule,  however, 


Partially 
separated 
placenta. 


Uterine 

cavity.  - 


Cervix. 


FIG.  144. — Interstitial  Pregnancy.      (Bumm). 

in  ovarian  pregnancy,  just  as  in  tubal  pregnancy.  It  is  possible 
for  the  ovum  to  be  destroyed  early  without  rupture  and  ovarian 
liematoma  may  result.  The  implantation  of  the  ovum  on,  or  in, 
the  ovary  does  not  differ  from  the  embedding  in  the  uterus  except 
that  a  definite  dccidua  is  wanting. 


SYMPTOMS  AND  SIGNS  OF  EXTRA-UTERINE  PREGNANCY 

There  are  no  symptoms  to  early  unruptured  extra-uterine  preg- 
nancy and  its  discovery  is  only  a  matter  of  chance.  Slight  pain 
in  the  ovarian  region  may  be  present.  Amenorrhea  may  be  a 
symptom,  but  cases  are  recorded  of  rupture  before  it  was  time 
for  another  menstrual  period,  the  patient  having  no  idea  she  was 
pregnant.  Suppression  of  menstruation  is  not  as  frequently  a 


SYMPTOMS  AND   SIGNS  347 

symptom  with  extra,-  as  with  intra-uterine  pregnancy,  perhaps 
due  to  the  presence  of  the  uterine  decidua,  and  if  rupture  or 
abortion  takes  place  in  the  tube  there  is  hemorrhage  from  the 
uterus.  Sometimes  the  patient  thinks  herself  pregnant  and  there 
may  be  present  signs  in  the  breasts,  bluish  discoloration  of  the 
anterior  vaginal  wall  and  the  introitus,  together  with  enlargement 
of  the  Fallopian  tube  on  bimanual  palpation. 

It  has  been  my  experience  that  the  patient  has  skipped  one 
menstrual  period  and  has  some  symptoms  of  pregnancy  before  the 
symptoms  of  rupture  occur.  These  are  sudden,  severe,  lancinating 
pain  in  the  groin,  bearing  down,  and  rectal  tenesmus,  followed 
at  once  by  faintness  and  sighing  respiration  with  collapse,  pallor, 
distention  of  the  abdomen,  a  feeble  rapid  pulse,  and  subnormal 
temperature.  Patients  seldom  die  of  this  first  hemorrhage,  but 
after  a  few  hours  there  is  another  attack  of  pain,  followed  by  greater 
collapse,  and  if  there  is  no  surgical  aid  death  may  follow. 

No  two  cases  are  alike,  one  will  bleed  rapidly  and  another  slowly. 
Further,  the  amount  of  collapse  does  not  seem  to  be  in  direct 
ratio  to  the  amount  of  blood  which  has  escaped  into  the  peritoneal 
cavity,  for  upon  operation  it  is  found  sometimes  that  when  the 
abdomen  is  full  of  blood  the  symptoms  have  not  been  severe.  In 
other  cases  most  alarming  symptoms  follow  the  extravasation  of 
a  small  quantity  of  blood. 

Pelvic  Hematocele. — If  the  blood  has  trickled  out  of  the  ostium 
of  the  tube,  as  in  tubal  abortion,  or  if  for  any  reason  the  discharge 
of  blood  is  intermittent,  there  will  be  a  series  of  attacks  of  pain, 
perhaps  a  week  or  two  apart.  In  these  cases  a  pelvic  hematocele 
is  generally  formed.  The  blood  collecting  in  the  pelvis  is  partly 
coagulated  and  is  walled  off  by  an  organized  membrane  of  perito- 
nitic  exudate.  Such  a  collection  may  be  a  solitary,  or  a  diffuse 
hematocele,  the  former  term  being  applied  to  a  smaller  collection 
of  blood  in  the  neighborhood  of  the  Fallopian  tube. 

Local  examination  shows  a  boggy  mass,  also  softness  of  the 
cervix,  and  pain  on  moving  it  forward  with  the  finger.  Bluish 
discoloration  of  the  vagina  may  be  present.  Colostrum  in  the 
breasts  is  an  unreliable  symptom.  In  some  cases  of  early  rupture 
there  is  a  uterine  discharge  of  a  brownish  color  which  may  con- 
tinue for  weeks.  This  is  due  to  the  disintegration  of  the  decidua 
in  the  uterine  cavity. 


348  EXTRA-UTERINE  PREGNANCY 

The  pelvic  hematocele  is  generally  situated  in  the  cul-de-sac 
of  Douglas.  If  the  uterus  happens  to  be  retroverted  and  the  cul- 
de-sac  obliterated  the  blood  may  be  effused  in  front  of  the  uterus 
and  in  that  case  the  hematocele  will  be  found  anteriorly.  A  fresh 
hematocele  is  flaccid  and  fluctuates;  an  old  one  is  hard  and  may 
be  of  uneven  density. 

If  rupture  does  not  result  in  death  and  there  is  no  surgical 
interference  pregnancy  may  continue  and  secondary  abdominal 
pregnancy  may  follow.  Then  the  symptoms  will  be  those  of  preg- 
nancy, with  more  pain  and  more  suffering  from  the  fetal  movements 
than  in  uterine  pregnancy.  False  labor  sets  in  at  term  with  uterine 
contractions  and  pain.  The  fetal  sac  contains  so  few  muscular 
fibres  that  it  can  not  contract  to  any  great  extent.  The  false  labor 
may  last  a  few  hours  or  a  number  of  days  and  is  followed  by  the 
death  of  the  child. 

Multiple,  combined,  and  repeated  tubal  pregnancies  are  reported 
in  the  literature.  Twin  tubal  pregnancies  occur  occasionally, 
both  embryos  being  in  the  same  tube  or  one  in  each  tube,  and 
Sanger  and  Krusen,  according  to  Whitridge  Williams,  have  reported 
cases  of  triplet  tubal  pregnancy,  all  of  the  embryos  being  of  the 
same  age.  Combined  extra-  and  intra-uterine  pregnancy  is  not 
very  rare.  Weibel  in  1905  had  collected  119  cases  from  the  lit- 
erature. This  class  includes  only  the  combined  pregnancies  in 
which  the  embryos  were  of  the  same  age,  and  not  the  cases  of 
uterine  pregnancy  occurring  in  the  presence  of  the  remains  of  an 
old  extra-uterine  pregnancy. 

There  have  been  many  cases  on  record  of  repeated  tubal  preg- 
nancy in  the  same  woman,  and  several  cases  of  this  have  fallen 
under  my  observation. 

DIAGNOSIS  OF  EXTRA-UTERINE  PREGNANCY 

EARLY  EXTRA-UTERINE  PREGNANCY 

The  positive  diagnosis  of  early  tubal  pregnancy  before  rupture 
has  been  made  and  has  been  proved  by  operation.  Such  a  diag- 
nosis is  based  on  the  symptoms  and  signs  of  early  pregnancy  and 
the  presence  of  a  tender  unilateral  tumor  of  the  tube  and  slight 
enlargement  of  the  uterus,  more;  especially  if  the  woman  has  been 


DIAGNOSIS  349 

sterile,  or  a  long  interval  has  elapsed  since  the  last  pregnancy.  A 
diagnosis  under  these  conditions  is  only  probable,  however.  Any 
patient  presenting  such  a  combination  of  symptoms  and  signs 
should  be  kept  under  continued  observations  until  the  diagnosis 
is  made  plain  or  an  operation  is  performed.  The  death  of  the  fetus, 
usually  between  the  fourth  and  the  ninth  week  of  pregnancy,  is 
signalized  by  the  discharge  of  the  uterine  decidua  and  by  more  or 
less  hemorrhage  from  the  uterus.  At  this  time  the  diagnosis  is 
apt  to  be  uterine  abortion.  Always  carefully  examine  the  ovaries 
and  tubes  in  cases  of  abortion  and  if  possible  get  shreds  of  extruded 
tissue  for  microscopic  examination.  In  exfoliative  endometritis  a 
cast  of  the  uterine  cavity  may  be  thrown  off,  and  therefore  the 
extrusion,  in  extra-uterine  pregnancy,  of  the  decidua  in  one  piece, 
triangular  in  shape,  is  not  proof  positive  of  the  existence  of  this 
disease,  but  may  be  classed  as  presumptive  evidence.  On  the 
other  hand,  the  cast-off  decidua  may  be  lost  at  an  early  date, 
perhaps  without  the  patient's  knowledge.  A  tubal  tumor  of  a 
size  corresponding  to  the  length  of  time  the  supposed  pregnancy 
has  existed,  a  slightly  enlarged  uterus,  a  relaxed  vagina  with 
bluish  discoloration,  a  vaginal  discharge  of  blood  and  shreds  of 
tissue,  and  pain  caused  by  pulling  the  cervix  forward  with  the 
finger  hi  the  vagina  make  the  diagnosis  of  tubal  pregnancy  most 
probable. 

The  symptoms  of  rupture  have  been  considered  under  the 
heading  of  symptoms,  page  347.  They  are  characteristic.  Sudden 
faintness  and  collapse,  together  with  severe  pain  in  the  region  of 
the  pelvis  in  a  woman  who  has  gone  over  her  period,  make  a  prob- 
able diagnosis  of  rupture  of  an  extra-uterine  pregnancy.  If  the 
patient  recovers  quickly  the  probabilities  are  in  favor  of  its  being 
tubal  abortion.  If  there  are  recurrent  attacks  and  a  hematocele 
can  be  made  out — a  boggy  mass  of  indefinite  outline — the  diagno- 
sis of  tubal  abortion  is  undoubted.  If  the  patient  goes  from  bad  to 
worse,  and  there  are  rigidity  of  the  abdomen,  increasing  abdomi- 
nal pain,  pallor,  sighing  respiration,  subnormal  temperature,  and 
a  thready  pulse,  the  diagnosis  is  tubal  rupture  and  the  abdomen 
should  be  opened  at  once.  After  the  first  attack  of  collapse  and 
pain,  there  is  to  be  felt  a  mass  in  the  pelvis. 


350 


EXTRA-UTERINE  PREGNANCY 


LATE   EXTRA- UTERINE   PREGNANCY 

In  the  later  stages  of  extra-uterine  pregnancy  a  correct  diagnosis 
is  seldom  made  until  full  term  is  reached.  In  the  later  months  of 
pregnancy  the  diagnosis  rests  on  finding  the  child  lying  outside 


FIG.  145.  —  Unruptured    Ampullar     Extra-uterine    Pregnancy,    Four    Months. 

(Williams.) 

of  the  uterus,  which  is  the  size  of  a  three1  months'  pregnancy.  The 
child  can  be  palpated,  the  fetal  heart  sounds  heard,  and  fetal 
movement  felt,  if  the  child  is  alive.  The  patient  has  had  more 


DIFFERENTIAL  DIAGNOSIS  3&1  J 

CHU.flC-E  OF  GSTE 

pain  than  is  usual  in  normal  pregnancy.    The  -?<wad  raa$r  bcfpassed  \  j  p  £ 
into  the  uterus  to  determine  that  it  is  empty. 

At  full  term  the  diagnosis  is  made  by  a  history  of  false  labor 
followed  by  a  gradual  decrease  in  the  size  of  the  abdomen.  The 
uterus  is  nearly  normal  in  size  and  displaced  by  a  large  tumor 
either  forward  or  backward.  The  child  can  be  palpated  and,  if 
alive,  the  fetal  heart  sounds  can  be  heard.  The  diagnosis  at  full 
term  is  easy  to  make,  whereas  previous  to  this  time  it  is  difficult. 

The  diagnosis  of  combined  intra-  and  extra-uterine  pregnancy 
is  seldom  made  previous  to  labor  or  operation.  Sometimes  in  the 
case  of  twins  when  a  child  has  been  born  from  the  uterus  and  there 
is  delayed  birth  of  a  second  child,  examination  leads  to  the  diagnosis 
of  extra-uterine  fetation.  Also,  operation  for  ruptured  extra- 
uterine  pregnancy  with  abdominal  hemorrhage  may  show  the  co- 
existence of  uterine  pregnancy. 


DIFFERENTIAL  DIAGNOSIS  OF  EXTRA-UTERINE  PREGNANCY 

Early  Extra-Uterine  Pregnancy  before  Rupture. — Here  any  enlarge- 
ment of  tube  or  ovary  not  greater  in  size  than  a  goose  egg  may 
be  mistaken  for  an  extra-uterine  fetation.  The  presence  of  the 
symptoms  and  signs  of  early  pregnancy  (see  Chapter  XXII,  page 
418)  and  the  fact  that  an  extra-uterine  sac  is  more  apt  to  be  tender, 
are  the  only  distinguishing  features. 

Pregnancy  in  a  retroverted  uterus  has  been  mistaken  for  extra- 
uterine  pregnancy.  A  thorough  examination,  if  necessary  with 
an  anesthetic,  ought  to  remove  all  doubt.  The  symptoms  which 
accompany  retro  version  of  a  gravid  uterus  should  be  borne  in 
mind,  viz.,  difficulty  in  micturition,  retention  of  urine,  pains  in 
the  pelvis,  and  constipation.  If  the  bladder  is  overdistended  it 
may  be  palpated.  Passage  of  the  catheter  establishes  the  diag- 
nosis. Uterine  fibroids  have  been  mistaken  for  a  gravid  tube, 
though  this  is  rare.  Fibroids  are  seldom  single  and  the  uterus 
is  apt  to  be  distorted  by  their  growth. 

Early  Extra-Uterine  Pregnancy  after  Rupture. — Symptoms  and 
signs  of  early  pregnancy  with  a  paroxysm  of  severe  abdominal 
pain,  collapse,  distention  and  rigidity  of  the  abdomen,  thready 
pulse  and  subnormal  temperature,  besides  meaning  ruptured 


352 


EXTR  A-UTK R I X K   PREGNANCY 


extra-uterine  pregnancy,  may  indicate  rupture  of  an  ovarian  cyst, 
or  torsion  of  the  pedicle  of  an  ovarian  cyst,  rupture  of  a  pyosalpinin 
or  even  of  an  appendiceal  abscess,  or  rupture  of  a  varicose  vex, 
of  the  broad  ligament.  The  treatment  is  the  same  in  all  of  these 
conditions,  immediate  opening  of  the  abdomen. 

If  the  rupture  has  been  into  the  folds  of  the  broad  ligament 

, ,      there  will  be   a   mass   of   irregular 

outline  at  the  side  of  the  uterus,  of 
doughy  consistency.  It  is  to  be 
differentiated  from  a  pelvic  inflam- 
matory mass  by  its  lack  of  hard- 
ness, by  the  absence  of  the  history 
of  infection,  and  by  the  absence  of 
the  signs  of  infection  in  vagina  and 
cervix. 

In  the  event  of  symptoms  of  acute 
rupture  in  conditions  simulating 
extra-uterine  pregnancy  the  history 
of  the  case  will  throw  light  on  the 
diagnosis.  In  the  case  of  an  ovarian 
tumor  the  history  will  show  the  pre- 
vious existence  of  a  tumor,  except 
in  the  case  of  a  small  one,  and  the 
uterus  is  not  enlarged;  in  the  case 
of  pyosalpinx  there  is  a  history  of 
genital  infection  and  the  tempera- 
ture is  apt  to  be  elevated,  also  the 
symptoms  of  hemorrhage, — weak 
heart,  pallor,  sighing  respiration, 
and  syncope, — are  absent.  In  the 
case  of  rupture  of  an  appendiceal 
abscess,  the  same  is  true  and  in 
addition  there  is  a  history  of  di- 
gestive disturbances,  constipation 
alternating  with  diarrhoea,  and,  usually,  previous  attacks  of 
right-sided  pain.  In  cases  of  chronic  rupture,  those  in  which  the 
symptoms  are  not  severe  and  prolonged,  uterine  abortion  is  one 
of  the  conditions  most  apt  to  be  mistaken  for  extra-uterine  preg- 
nancv.  If  there  is  any  doubt  at  all  that  the  case  is  one  of  uterine 


FIG.  146. — Median  Section  of 
the  Uterus  of  a  Case  of  Isthmial 
Tubal  Pregnancy  of  about  Two 
Months,  Showing  the  Decidual 
Modification  of  the  Endometrium. 
(Couvelaire.) 


DIFFERENTIAL  DIAGNOSIS  353 

abortion,  ether  should  be  given  and  a  thorough  bimanual  exami- 
nation made.  The  uterine  hemorrhage  in  cases  of  extra-uterine 
pregnancy  is  generally  of  less  amount  than  in  cases  of  abortion 
and  the  clots  are  less  frequently  passed.  The  pain  of  rupture  is 
a  severe,  agonizing  sensation,  one  that  can  not  be  endured;  in 
the  beginning  it  is  unilateral.  The  pain  of  abortion  is  that  of 
labor,  beginning  as  an  aching,  drawing  pain  in  the  lumbar  region 
radiating  toward  the  hypogastrium. 

The  changes  in  the  size  and  consistency  of  the  uterus  are  more 
marked  in  uterine  than  in  extra-uterine  pregnancy.  In  the  case 
of  acute  pyosalpinx  or  an  exacerbation  of  a  chronic  pyosalpinx 
there  are  no  softening  of  the  cervix  and  no  pain  when  the  cervix 
is  moved  forward  as  in  the  case  of  extra-uterine  pregnancy.  In 
the  case  of  rupture  of  varicose  veins  of  the  broad  ligament,  a  rare 
event,  there  is  nothing  to  point  toward  a  diagnosis  unless  the 
patient  has  been  under  observation  previous  to  the  rupture. 

According  to  Baumgarten  and  Poffer  (Wiener  klinische  Wochen- 
schrift,  1906,  No.  12)  acetonuria  is  present  in  extra-uterine  preg- 
nancy. They  examined  the  urine  of  one  hundred  patients  and 
were  able,  by  detecting  acetonuria,  to  distinguish  between  extra- 
uterine  pregnancy  and  other  pelvic  tumors. 

Late  Extra-uterine  Pregnancy. — If  the  walls  of  a  pregnant  uterus 
are  abnormally  thin,  and  the  walls  of  the  mother's  abdomen  are 
also  thin,  the  fetus  may  be  so  plainly  felt  that  a  uterine  may  be 
mistaken  for  an  extra-uterine  fetation.  Careful  bimanual  pal- 
pation will  determine  that  the  fetus  is  in  the  uterus.  So,  also,  a 
sacculated  pregnant  uterus  may  simulate  extra-uterine  pregnancy, 
as  well  as  pregnancy  in  a  bicorned  uterus.  In  the  latter  case  an 
ether  examination  may  serve  to  differentiate. 

A  late  extra-uterine  pregnancy  with  an  excess  of  hydramnios 
may  simulate  ovarian  cyst.  If  the  fetus  can  be  outlined  by  pal- 
pation, or  the  fetal  heart  heard,  the  diagnosis  is  easy. 

The  consideration  of  pregnancy  in  abnormal  uteri,  such  as 
bicorned  and  rudimentary,  will  be  found  in  the  chapter  on  preg- 
nancy, page  -132. 


CHAPTER  XX 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  VAGINA 

Anatomy,  p.  3,54:    Vaginal  discharge,  p.  3.5.3.     Age  changes,  3.36. 

Malformations  of  the  vagina,  p.-  356:  Congenital  malformations,  p.  356. 
Acquired  stenosis  and  atresia  of  the  vagina,  p.  359. 

Inflammations,  p.  361 :  Acute  vaginitis,  p.  362.  Chronic  vaginitis,  p. 
363.  Condylomatous  vaginitis,  p.  363.  Emphysematous  vaginitis,  p.  364. 
Mycotic  vaginitis,  p.  364.  Ulcerative  vaginitis,  p.  364.  Senile  vaginitis,  p. 
36.5.  Tuberculous  vaginitis,  p.  36.3.  Syphilitic  vaginitis,  p.  365. 

Displacements  of  the  vagina,  p.  366:  Cystocele,  p.  366.  Rectocele,  p. 
36!).  Hernia  or  enterocele,  p.  371. 

Injuries  of  the  vagina,  p.  371 :  Lacerations  of  the  perineum  and  pelvic 
floor,  j).  371.  Other  injuries,  p.  372. 

Foreign  bodies  in  the  vagina,  p.  377.    Gas  in  the  vagina,  p.  378. 

Vaginismus,  p.  ,'378. 

New  growths  of  the  vagina,  p.  379. 

Fistulaj  of  the  vagina,  p.  384. 

ANATOMY 

THE  vagina  is  a  slit  in  the  pelvic  floor  extending  from  the  hymen 
to  the  cervix  uteri  and  lying  between  the  bladder  in  front  and 
the  rectum  behind.  It  is  nearly  parallel  to  the  plane  of  the  brim 
of  the  true  pelvis,  and,  with  the  patient  in  the  upright  posture, 
makes  an  angle  with  the  horizon  of  about  60°.  When  seen  in  a 
median  longitudinal  section  the  slit  of  the  vagina  shows  an  S  curve, 
the  height  of  the  first  anterior  protuberance  of  the  S  being  at  the 
summit  of  the  perineal  body.  (See  Figs.  6,  p.  44  and  So,  p.  219). 
In  horizontal  section  in  its  middle  course  it  is  seen  as  an  H-shaped 
opening.  (See  Fig.  lol,  p.  374.)  Like  the  cavity  of  the  uterus  it  is 
funnel-shaped,  being  larger  above  and  smaller  below,  and  it  has  two 
walls,  an  anterior  and  a  posterior,  which  are  in  apposition  unless 
the  vagina  is  distended. 

The  anterior  wall  extends  from  the  hymen  below,  to  the  cervix 
above,  the  anterior fornix  being  the  space  formed  between  the  intra- 
vaginal  portion  of  the  cervix  and  the  upper  portion  of  the  anterior 

354 


ANATOMY  355 

wall.  The  length  of  the  anterior  wall  is  from  two  to  two  and  a  half 
inches  (5  to  6  centimeters).  In  its  lower  portion  it  is  closely 
united  with  the  urethra,  but  higher  up  is  surrounded  by  loose 
areolar  tissue. 

The  posterior  wall  extends  from  the  hymen  to  the  cervix  uteri. 
It  is  three  inches  (7.5  centimeters)  long  or  nearly  an  inch  longer 
than  the  anterior  wall.  The  space  between  the  vaginal  portion 
of  the  cervix  and  the  upper  part  of  the  posterior  wall  is  called 
the  posterior  fornix.  It  is  deeper  than  the  anterior  fornix. 

The  mucous  membrane  of  the  vagina  is  arranged  in  transverse 
folds  or  ruga).  In  the  lower  part  of  the  centre  of  each  wall  is  a 
single  or  double  longitudinal  thickening  about  seven-eighths  inch 
long,  known  as  the  column  of  the  vagina.  The  anterior  column  is 
the  larger. 

The  vagina  is  made  up  of  three  coats,  the  mucous  membrane, 
the  muscular  coat,  and  the  erectile  tissue  lying  between  the  two. 
The  arrangement  of  the  mucous  membrane  in  folds  has  been 
described.  The  epithelium  covering  the  surface  of  the  mucous  mem- 
brane is  of  the  squamous  variety.  There  are  no  functioning  glands, 
although  the  presence  of  gland  tissue  in  the  mucous  membrane 
has  been  proved  by  von  Herff  and  R.  Meyer.  The  muscular  coat 
consists  of  two  layers,  an  external  longitudinal,  the  stronger,  and 
an  internal,  weaker,  circular  layer.  The  loose  connective  tissue 
uniting  the  mucous  membrane  with  the  muscular  coat  contains  a 
plexus  of  veins  which  are  arranged  similarly  to  the  veins  in  other 
erectile  tissues.  Because  of  its  opening  near  the  anus  and  the 
urethra,  and  its  being  invaded  by  the  penis,  the  vagina  is  especially 
subject  to  infection  from  outside.  Bacteria  may  be  brought  to  it 
from  the  uterus  and  trauma  may  come  from  childbearing. 

Vaginal  Discharge. — Although  under  normal  conditions  posses- 
sing no  functioning  glands  and  therefore  no  secretion  proper,  the 
surface  of  the  vagina  is  covered  by  cast  off  epithelial  cells  and 
also  bacteria  with  moisture  having  an  acid  reaction.  This  has  a 
white  creamy  color  and  is  not  enough  in  amount  to  attract  the 
woman's  attention.  The  acidity  of  the  fluid  may  be  due  to  the 
lactic  acid  bacterium  of  Doderlein,  though  authorities  are  not 
agreed  on  this  point.  Be  that  as  it  may,  pathogenic  bacteria,  unless 
("specially  virulent,  do  not  live  long  in  a  healthy  vagina,  not  rinding 
a  good  culture  medium  or  being  killed  by  the  microorganisms 


356  DISEASES  OF  THE  VAGINA 

already  there.  Under  pathological  conditions  an  excess  of  alkaline 
secretion  from  a  cervical  catarrh  may  neutralize  the  acidity  of  the 
vagina  and  render  it  alkaline,  thus  furnishing  an  opportunity  for 
the  growth  of  disease-producing  germs. 

Age  Changes. — In  the  child  the  vagina  is  narrow  and  there  are 
many  ruga'.  Its  \valls  are  in  close  apposition.  In  the  adult 
nulliparous  married  woman  the  vagina  is  more  capacious,  the 
widening  being  more  in  the  upper  than  in  the  lower  portion. 
After  childbearing  the  vagina  loses  some  of  its  folds,  is  larger,  and 
may  show  alterations  in  shape  because  of  its  attachments  being 
stripped  from  the  cervix,  or  from  laceration  of  the  perineum. 

With  the  onset  of  the  menopause  atrophic  changes  begin.  The 
mucous  membrane  loses  its  ruga}  and  becomes  smooth,  and  the 
vagina  becomes  contracted.  In  its  upper  portion  the  fornices  are 
obliterated  because  of  atrophy  of  the  cervix  and  shrinking  of  the 
vaginal  walls. 

MALFORMATIONS  OF  THE  VAGINA 

Malformations  of  the  vagina  are  congenital  or  acquired.  As  the 
Aragina  as  well  as  the  uterus  is  derived  from  the  coalescence  of 
Miiller's  ducts  it  partakes  of  the  congenital  malformations  of  the 
uterus. 

Congenital  Malformations. — These  are:  absence  of  the  vagina, 
atresia  of  the  vagina,  septate  vagina,  double  vagina,  and  per- 
sistence of  a  Miiller's  duct,  also  the  persistence  of  Gartner's  duct. 

Absence  of  the  Vagina. — This  is  not  a  very  uncommon  malfor- 
mation, instances  of  it  appearing  constantly  in  the  periodical 
literature.  It  is  associated  with  a  greater  or  less  degree  of  lack 
of  development  of  the  uterus,  the  uterus  being  represented  gen- 
erally by  a  small  knob  of  tissue.  The  ovaries  and  tubes  may  or 
may  not  be  present.  If  the  ovaries  arc  present  the  patient,  other- 
wise perfectly  formed  as  regards  figure,  external  genitals,  breasts, 
and  hair,  suffers  from  painful  menstrual  molimina,  and  an  oper- 
ation for  the  removal  of  the  ovaries  may  be  necessary.  The  anomaly 
occurs  without  assignable  cause  in  well-nourished  women  in  other 
respects  fully  developed. 

The  diagnosis  is  established  by  noting  the  absence  of  the  introitus 
vaginae  and  by  the  bimanual  recto-abdominal  touch  practised 


MALFORMATIONS  OF  THE  VAGINA  357 

with  the  patient  under  the  influence  of  an  anesthetic.  Something 
is  learned  also  by  palpation  through  the  rectum  with  a  sound 
placed  in  the  urethra  and  bladder.  As  a  rule  no  vestige  of  the 
vagina  can  be  found  in  these  cases.  The  entire  absence  of  the 
ovaries  can  not  be  determined  surely  without  an  abdominal  section, 
but  failure  to  find  them  in  a  case  where  all  the  conditions  for 
examination  are  favorable,  i.e.,  lax  and  thin  abdominal  walls, 
together  with  the  absence  of  menstrual  molimina,  makes  the 
diagnosis  reasonably  certain. 

Atresia  of  the  Vagina  (Congenital). — Vaginal  atresia  is  due  to 
the  fact  that  the  Miiller's  ducts  fail  to  coalesce  properly  throughout 
their  entire  course,  and  the  lower  end  of  the  vagina  may  fail  to 
reach  the  hymen.  As  a  rule  there  is  some  portion  of  the  unoccluded 
vagina  just  under  the  cervix.  In  cases  of  congenital  atresia  of  the 
vagina  the  vagina  has  been  found  dilated  with  secretion  so  that  it 
bulged  beyond  the  vulva,  and  has  been  known  to  cause  retention  of 
urine  in  the  new-born  because  of  pressure  on  the  urethra. 

Occlusion  of  the  vagina  is  to  be  differentiated  from  imperforate 
hymen,  the  latter,  being  developed  from  the  margins  of  the  urogeni- 
tal  sinus,  is  not  a  complete  obstructive  membrane.  It  is  likely 
that  when  the  hymen  is  closed  the  closure  is  the  result  of  adhesive 
inflammation.  The  hymen  can  generally  be  recognized  as  a 
separate  structure  below  the  introitus  vagina?. 

Any  defect  of  the  vagina  that  causes  retention  of  the  uterine 
secretions  should  be  diagnosed  at  birth  or  soon  after. 

In  the  case  of  double  uterus  and  vagina  one  vagina  may  appear 
as  a  blind  sac  running  beside  the  well-formed  vagina.  It  is  thought 
now  that  most  cases  of  atresia  of  the  vagina  owe  their  origin  to 
inflammatory  processes,  perhaps  during  intra-uterine  life,  although 
there  are  cases,  mainly  those  associated  with  uterine  abnormalities, 
that  arc  due  to  failure  of  development  pure  and  simple. 

The  diagnosis  is  generally  made  by  chance  or  by  the  occurrence 
of  hematocolpos  or  hematometra  due  to  retained  secretions  in 
the  vagina  or  uterus. 

Septate  vagina  and  double  vagina  occur  when  the  septum  between 
the  Miillerian  ducts  is  partially  or  not  at  all  absorbed.  The  partial 
form  is  more  often  observed,  although  all  forms  are  rare.  The 
septum  may  be  placed  diagonally  so  that  it  has  the  appearance 
of  a  transverse  septum,  thus  partially  occluding  one  side  of  the 


35S  DISEASES  OF  THE  VAGINA 

vagina:  it  may  extend  a  part  of  the  length  of  the  vagina,  more 
often  in  the  lower  part,  making  two  canals  below  and  one  above, 
or  it  may  be  only  a  ridge  on  the  anterior  or  posterior  wall  of  the 
vagina.  If  one  M filler's  duct  persists  in  the  upper  part  of  the 


Fie.   147. — Double   I'terus  and   Double  Vaccina.      (Kelly.) 

wall  of  a  well-developed  vagina  and  is  connected  above  with  a 
rudimentary  supernumerary  uterus  while  having  no  opening 
below,  it  may  become  dilated  by  retained  secretions  and  appear 
as  a  cyst.  Freund  and  others  have  reported  such  cases. 


MALFORMATIONS  OF  THE  VAGINA  359 

Several  cases  of  double  vagina  have  been  reported,  notably  one 
of  double  vagina  and  double  uterus  reported  by  H.  A.  Kelly 
("  Operative  Gynecology,"  2nd  edition,  page  210.)  (See  Fig.  147.) 

Gartner's  duct,  which  in  the  embryo  extends  as  a  small  canal 
through  the  side  of  the  uterus  or  the  broad  ligament,  the  cervix, 
and  the  lateral  or  anterior  wall  of  the  vagina  nearly  to  the  introitus 
vaginae,  may  persist  in  the  wall  of  the  adult  vagina.  This  may, 
rarely,  give  rise  to  cysts  or  even  to  an  abscess. 

,  Retention  of  secretions  due  to  atresia  of  the  vagina,  hemato- 
colpos,  will  be  considered  under  acquired  stenosis  and  atresia  in 
the  section  on  inflammations. 

The  diagnosis  of  malformations  is  made  by  inspection  and  by 
digital  examination.  A  small  speculum  is  necessary  and  sometimes 
a  Kelly  cystoscope  serves  well  for  a  view  of  an  undeveloped 
vagina.  Bimanual  recto-abdominal  touch  will  determine  the 
condition  of  the  uterus  and  ovaries. 

Acquired  Stenosis  and  Atresia  of  the  Vagina. — Stenosis  of  the 
vagina  is  a  constriction  or  narrowing  of  the  canal,  while  atresia  is  a 
complete  closure  or  obliteration  of  it. 

J.  Vcit  ("Handbuch  der  Gynakologie,"  Bd.  Ill,  1908)  thinks 
that  most  of  the  forms  of  vaginal  atresia  that  cause  retention  of 
secretions  as  seen  in  the  adult  (hematocolpos)  are  to  be  classed 
as  acquired,  and  assigns  adhesive  inflammation  in  the  first  years 
of  life  as  a  cause.  This  inflammation  is  not  as  a  rule  severe  and 
has  no  symptoms  often.  We  know  of  the  frequency  of  gonorrheal 
vulvo-vaginitis  in  little  girls,  and  also  that  inflammatory  affections 
of  the  vagina  are  found  in  septicemia,  scarlet  fever,  and  diphtheria. 
Also,  bacteria  find  ready  entrance  to  the  vagina  in  typhoid  fever, 
dysentery,  and  similar  affections.  Taken  in  connection  with  the 
frequency  with  which  traces  of  inflammatory  action — for  example, 
adhesions  of  the  prepuce4  to  the  clitoris — are  found  in  adults  upon 
careful  search,  then4  seems  to  be  ample  ground  for  the  theory  that 
this  sort  of  atresia  originates  in  adhesive  inflammation. 

In  adults  the  cause4  of  cicatricial  stenosis  is  inflammatory  action 
involving  the  submucous  and  muscular  layers,  due  to  injuries 
following  childbirth,  to  caustic  applications  to  the  vagina,  to 
improperly  performed  operations  on  the  vagina,  to  foreign  bodies 
left  in  the  vagina,  such  as  neglected  pessaries,  and  to  vaginitis 
phlegmonosa  disseccans.  As  a  result  there  are  found  in  the  vagina 


360  DISEASES  OF  THE  VAGINA 

crcsccntic  folds,  ring-like  rial-rowings,  transverse  septa  with  minute 
openings,  all  being  forms  of  stenosis,  or  there  is  a  general  shutting 
up  of  the  entire  canal,  atresia.  This  atresia  may  be  caused  by  a 
thin  membrane,  by  a  broad  cicatrix  several  centimeters  thick, 
or  by  the  entire  destruction  of  the  vagina. 

Atresia  or  stenosis  results  in  difficulty  in  coitus  and  in  labor. 
In  the  congenital  form  of  atresia  of  the  genital  organs  there  is 
apt  to  be  diminished  desire  for  sexual  intercourse,  especially  if 
the  ovaries  are  undevelopd.  Another  result  of  atresia  is  hemato- 
colpos,  or  accumulation  of  menstrual  blood  and  uterine  secretions 
in  the  vagina.  These  cases  are  generally  first  seen  in  girls  who 
have  passed  the  age  of  puberty  without  the  appearance  of  the 
menstrual  flow.  They  may  experience  pain  in  the  abdomen. 
Examination  shows  a  tumor  behind  the  pubes  that  increases  in 
size  at  each  menstrual  period  and  diminishes  in  the  interval. 
On.  inspection  of  the  vulva  there  is  to  be  noted  a  bulging  outward 
in  the  region  of  the  introitus  vagina1  of  an  elastic  tumor.  The 
hymen  is  to  be  distinguished  as  a  separate  membrane.  If  the 
septum  of  the  vagina  is  thin  the  dark  color  of  the  retained  blood 
may  manifest  itself  through  the  membrane.  The  bimanual  recto- 
abdominal  touch  determines  the  presence  of  a  fluctuating  tumor 
in  the  situation  of  the  vagina. 

If  the  accumulation  of  blood  and  uterine  secretions  has  dilated 
the  uterus,  hematometra,  it  may  be  possible,  with  the  aid  of  an 
anesthetic,  to  palpate  the  enlarged  uterus.  Dilatation  of  the 
Fallopian  tubes  from  the  same  cause,  hematosalpinx,  sometimes 
results.  In  the  latter  event  there  may  be  an  escape  of  fluid  through 
the  ostium  abdominale  of  the  tube  into  the  peritoneal  cavity  with 
resulting  peritonitis  and  symptoms  of  a  severe  grade.  The  danger 
of  causing  such  extrusion  of  fluid  should  be  borne  in  mind  in  making 
the  bimanual  touch  and  the  amount  of  force  used  should  be  carefully 
limited.  (See  Chapter  XXI,  p.  398). 

Diagnosis. — The  diagnosis  of  stenosis  and  atresia  of  the  vagina 
offers  few  difficulties.  The  examining  finger  detects  folds  and 
ridges  and  partial  narrowings,  also  double  vagina,  if  present.  A 
small  speculum  is  generally  indicated,  for  with  it  the  physician 
gets  a  better  view  of  an  abnormally  narrowed  vagina.  An  open 
canal  with  an  elastic  tumor  by  its  side  makes  probable  a  dilated 
rudimentary  vagina.  Cyst  of  the  vagina  must  be  excluded,  how- 


INFLAMMATIONS   OF  THE   VAGINA  361 

ever,  and  this  can  be  done  by  determining  the  normal  state  of 
the  uterus,  tubes,  and  ovaries,  as  rudimentary  vagina  is  seldom 
found  with  the  other  uterine  organs  perfectly  normal.  In  all 
cases  it  is  important  to  investigate  the  uterus  and  tubes. 

Differential  Diagnosis. — Acquired  stenosis  and  atresia  must  be 
differentiated  from  the  congenital  malformations,  from  vulvitis 
with  atresia,  and  from  vaginismus.  The  congenital  malforma- 
tions are  of  relatively  rare  occurrence  and  are  associated  with 
other  defects  of  development  in  uterus,  tubes,  or  ovaries,  their 
salient  characteristics  having  been  referred  to.  In  adhesive  vul- 
vitis there  are  apt  to  be  traces  of  inflammatory  action  (adhesions) 
about  the  clitoris  and  nymphse,  as  well  as  at  the  introitus  vaginae. 
There  may  be  a  history  of  gonorrhea,  in  this  case  look  for  cicatri- 
zation or  redness  in  the  neighborhood  of  the  vulvo- vaginal  glands ; 
or  there  may  be  a  history  of  diabetes.  Vaginismus  is  characterized 
by  painful  and  spasmpdic  contractions  of  the  muscles  of  the  pelvic 
floor,  especially  those  about  the  lower  vagina.  In  cases  of  doubt 
the  administration  of  an  anesthetic  will  relieve  all  spasm. 


INFLAMMATIONS  OF  THE  VAGINA 

(Vaginitis  or  Colpitis) 

Infection  of  the  vagina  depends  on  the  number  and  vitality 
of  the  pathogenic  bacteria  that  have  found  their  way  into  it;  also 
on  the  state  of  health  of  the  epithelium  of  the  mucosa  of  the  vagina. 
Any  direct  injury  of  the  epithelium,  or  change  in  its  character  due 
to  a  uterine  catarrh  favors  the  development  of  infective  organisms, 
and  their  entrance  into  the  tissues.  Just  what  bacteria  are  present 
as  causative  agents  in  any  given  case  it  is  not  always  easy  to 
determine;  those  that  are  most  often  found  are  the  streptococcus, 
the  staphylococcus,  the  colon  bacillus,  the  tubercle  bacillus,  the 
gonococcus,  and  a  gas-producing  bacillus. 

Vaginitis  is  relatively  more  common  in  children  than  in  adults, 
probably  because  of  the  softer  epithelium  in  childhood.  In  children 
vulvo-vaginitis  of  gonorrheal  origin  is  not  uncommon,  and  vagi- 
nitis  is  a  frequent  concomitant  of  the  acute  infectious  diseases. 
In  adults  vaginitis  is  a  rare  disease. 

Etiology. — The   following   may   be   mentioned   as   predisposing 


302  DISEASES  OF  THE  VAGINA 

and  exciting  causes  of  vaginitis:  Retained  discharges  from  an 
insuiiicient  opening  in  the  hymen;  irritation  from  excessive 
venery  or  masturbation;  congestion  from  pregnancy  or  abdominal 
tumor,  or  organic  disease  of  the  heart,  liver,  or  kidneys;  gaping 
of  the  vulvo-vaginal  orifice:  douches  of  irritating  substances, 
such  as  strong  corrosive  sublimate;  foreign  bodies,  such  as  pes- 
saries and  tampons;  oxyuris  vermicularis;  injuries  received  at 
labor  and  abortion,  and  recto-  and  vesico- vaginal  fistula?. 

ACITK  VAGIXITIS 

Pathology. — In  the  mild  cases  it  is  characterized  by  a  reddened, 
swollen,  granular  mucosa  which  is  bathed  in  an  abundant  thin 
purulent  discharge.  The  entire  vagina  is  usually  involved.  In 
the  severe  cases,  swelling  and  hyperemia  increase  and  excoriations 
and  even  necrosis  may  occur.  In  puerperal  conditions  and  in  the 
acute  infectious  diseases  the  mucosa  may  be  covered  with  a  whitish- 
gray  or  greenish  deposit  or  by  a  false  membrane  made  up  of  the 
necrosed  upper  portion  of  the  mucosa — pseudo-diphtheritic  vaginitis. 
Cases  of  true  diphtheritic  inflammation,  due  to  the  Klebs-Loeffler 
bacillus,  have  been  described,  though  they  are  rare. 

In  certain  extremely  severe  cases  the  inflammatory  process 
extends  to  the  tissues  about  the  vagina  and  there  is  a  paravaginitis. 
This  is  the  case  in  an  erysipelatous  vaginitis  similar  to  the  erysipelas 
of  the  skin,  a  rare  disease,  and  in  paravaginitis  pJdegmonosa  dis- 
siccans,  which  sometimes  accompanies  typhoid  fever.  In  the 
phlegmonous  variety  the  whole  or  the  greater  part  of  the  tube  of 
the  vagina  is  cast  off  as  a  slough  with  subsequent  stenosis. 

Symptoms. — Burning  pain  referred  to  the  vulva,  a  profuse 
leucorrheal  discharge,  generally  purulent  in  character  and  irritating 
to  the  vulva,  smarting  on  urination  if  the  vulva  is  involved  and 
also  if  urethritis  is  present,  as  in  the  gonorrheal  form,  a  sense  of 
fullness  in  the  pelvis,  and  backache,  are  the  usual  symptoms. 
\  ulvitis  goes  with  vaginitis  in  many  cases,  especially  in  children. 
The  constitutional  symptoms  are  not  marked,  the  temperature 
seldom  going  above  101°  F..  except  in  the  streptococcic,  diphthe- 
ritic, and  paravaginitic  forms. 

Diagnosis.— The  patient  is  placed  in  the  Sims  position  and  the 
labia  are  separated.  The  character  and  amount  of  discharge  are 


363 

noted  and  a  finger  placed  in  the  vagina  finds  that  it  is  hot.  In 
the  gonorrheal  variety,  which  is  relatively  rare  and  is  secondary  to 
infection  of  Bartholin's  glands,  the  urethra,  and  cervical  canal, 
the  discharge  is  generally  of  a  greenish-yellow  color.  The  smallest 
Sims  speculum  that  will  serve  is  used  because  the  vagina  is 'very 
sensitive.  The  mucous  membrane  shows  some  of  the  many  char- 
acteristics described  under  the  pathology  of  acute  vaginitis.  If 
the  vaginal  discharge  originates  from  the  uterus  or  an  abscess 
discharging  into  the  vagina  instead  of  from  the  vagina  itself,  the 
speculum  examination  will  settle  this  point. 

CHRONIC  VAGINITIS 

Pathology. — Chronic  vaginitis  may  succeed  acute  vaginitis,  or, 
more  often,  may  be  of  a  chronic  type  from  the  beginning.  It  is 
apt  to  result  from  the  irritation  from  pessaries  or  tampons,  or 
other  foreign  bodies.  In  the  gonorrheal  form  it  is  usually  secondary 
to  gonorrheal  infection  of  the  uterus,  Bartholin's  glands,  or  the 
canal  of  the  cervix  uteri. 

The  disease  is  generally  confined  to  certain  portions  of  the 
vagina  rather  than  to  the  entire  surface,  as  it  is  in  the  acute  form. 
The  affected  portions  are  reddened,  often  mottled  with  slight 
ecchymoses,  or  they  arc  brown  in  color  from  old  deposits  of  blood 
pigment.  The  surface  is  granular,  or  glazed  and  smooth  and  free 
from  ruga\  Microscopically  it  is  seen  that  the  surface  epithelium  is 
somewhat  thinner  than  normal,  whereas  the  submucous  tissue  is 
thick,  dense,  and  infiltrated  with  small  round  cells;  sometimes 
blood  pigment  shows  in  deposits  in  places.  In  granular  vaginitis 
the  granulations  on  the  surface  are  crescent-shaped,  small  in  size, 
and  pretty  generally  scattered  over  the  surface  of  the  vagina. 
Certain  special  varieties  of  chronic  endometritis  are  observed. 

Gonorrheal  vaginitis  should  be  mentioned  as  a  variety,  although 
it  has  few  characteristics  that  distinguish  it  from  simple  vaginitis. 
It  is  generally  secondary  to  gonococcus  infection  elsewhere  and 
the  discharge  is  apt  to  be  of  a  greenish  color. 

Condylomatous  V(t<jinitix. — Condylomata  similar  to  those  found 
about  the  vulva,  but  set  not  so  close  together,  are  to  be  found 
sometimes  in  vagina1  that  have  been  subject  to  long-continued 
irritations,  as  from  gonorrheal  endocervicitis.  The  condylomata 


364  DISEASES  OF  THE  VAGINA 

may  be  scattered  over  a  large  or  a  small  area  in  the  vagina.  They 
show  under  the  microscope  hyperplasia  of  the  papilla)  accompanied 
by  secondary  epithelial  proliferation. 

Emphysematous  Vaginitis. — This  variety  occurs  most  often 
during  pregnancy  and  occasionally  during  the  puerperium,  and 
is  characterized  by  the  presence  in  the  vaginal  walls  of  small  cysts, 
generally  not  much  larger  than  a  pea,  and  containing  gas.  They 
may  appear  to  be  bluish  in  color  due  to  the  thinness  of  their  walls. 
They  are  due  to  a  gas-producing  bacillus  the  exact  nature  of  which 
has  not  been  determined,  and  are  developed  in  the  connective- 
tissue  spaces.  Sometimes  the  cysts  are  as  large  as  a  filbert.  On 
pressure  with  the  finger  the  cyst  disappears,  and  on  opening  it 
with  a  knife  gas  escapes. 

Mycotic  Vaginitis. — This  is  a  form  of  vaginitis  in  which  there 
is  a  growth  of  a  fungus  in  the  vagina,  the  Oidium  albicans.  The 
walls  of  the  vagina  are  covered  with  large  numbers  of  grayish- 
brown,  slightly  elevated  masses  which  are  easily  detachable. 
Beneath  them  the  mucosa  is  swollen  and  eroded.  Under  the 
microscope  the  masses  are  seen  to  be  made  up  of  epithelial  cells 
and  the  spores  and  mycelium  of  Oidium  albicans.  It  has  been 
thought  that  the  dark  color  is  due  to  blood-coloring  matter. 

Ulcerative  Vaginitis. — -Ulcerative  vaginitis  is  a  term  used  to 
distinguish  the  form  of  the  disease  in  which  the  mucosa  has  been 
destroyed  by  ulceration,  as  in  the  case  of  an  ill-fitting  pessary. 
Following  the  true  form  of  ulceration  in  which  the  submucous  tissue 
is  involved  a  cicatrix  results. 

An  interesting  case  of  ulcerative  vaginitis  in  a  case  of  bacillary 
dysentery  has  been  reported  by  M.  M.  Canavan  (Boston  Med.  and 
Sury.  Jour.,  Nov.  11,  1909,  page  705).  In  this  case  a  woman  fifty- 
one  years  old,  an  inmate  of  the  Danvors  State  Hospital  for  the 
Insane  for  four  years,  was  affected  by  bacillary  dysentery  during  an 
epidemic  of  the  disease  in  190S.  She  died,  just  after  a  vaginal 
hemorrhage,  on  the  fourteenth  day  of  her  illness.  At  the  autopsy 
the  following  condition  was  found,  to  explain  the  hemorrhage  and 
a  bloody  vaginal  discharge  which  had  been  noted  during  the  last 
six  days  of  her  illness.  The  surface  of  the  vagina  was  dull  brown- 
ish-gray in  color  and  was  covered  with  a  tenacious  pigmented  exu- 
date  and  there  were  clusters  of  deep-notched  winding  ulcers  at  the 
fornices  of  the  vagina. 


INFLAMMATIONS  OF  THE   VAGINA  365 

Senile  Vaginitis. — In  senile  vaginitis,  a  form  of  vaginitis  peculiar 
to  women  who  have  passed  the  menopause,  the  mucous  membrane 
is  atrophic  and  therefore  poorly  nourished.  The  irritation  of  the 
vagina  from  a  uterine  discharge  is  apt  to  proceed  to  the  stage  of 
ulceration,  generally  many  small  scattered  ulcers  being  present. 
These  enlarge,  coalesce,  cause  hemorrhage  by  the  erosion  of  small 
vessels,  and  form  scar  tissue.  There  may  be  adhesions  between 
the  walls  of  the  vagina.  The  disease  is  a  common  one  in  women 
over  sixty  years  of  age. 

Tuberculous  Vaginitis* — This  variety  is  practically  always  second- 
ary to  tuberculosis  elsewhere,  although  a  problematical  case  of 
primary  tuberculosis  of  the  vagina  has  been  reported  by  Carl 
Friedlander  and  Olshausen.  The  disease,  not  a  common  one, 
occurs  in  the  form  of  one  or  more  ulcerations,  generally  situated 
in  the  neighborhood  of  the  cervix.  The  ulcers  are  flat,  circum- 
scribed, with  infiltrated  hyperemic  margins,  the  base  covered 
with  yellowish-gray  material  or  studded  with  tubercles.  Histo- 
logically  the  floor  of  the  ulcer  consists  of  granular,  caseous  material, 
beneath  which  the  tissue  is  infiltrated  with  typical  miliary  tuber- 
cles or  diffuse  tuberculous  tissue.  The  diagnosis  is  made  by  the 
microscope. 

Syphilitic  vaginitis  needs  only  to  be  mentioned.  Chancres, 
ulcers,  or  gummata  may  be  found  in  the  vagina.  They  are  rare 
and  are  diagnosed  by  the  characteristic  lesions  of  the  disease  in 
other  parts  of  the  body,  by  the  history  of  syphilis,  and  by  the  de- 
tection of  the  spirochaeta  pallida  in  the  discharge. 

Symptoms. — The  symptoms  of  chronic  vaginitis  are  vaginal 
discharge,  generally  purulent  in  character,  a  sensation  of  fullness 
in  the  pelvis,  perhaps  itching  of  the  vulva  with  smarting  on  urina- 
tion if  the  vulva  also  is  affected.  The  general  health  may  suffer 
as  a  result  of  the  irritation  and  consequent  loss  of  sleep,  but  there 
are  no  characteristic  constitutional  symptoms.  Leucorrhea  may  be 
the  only  symptom. 

Diagnosis. — The  patient  is  in  the  Sims  position.  A  Sims  specu- 
lum is  employed.  It  is  noted  that  the  vagina  is  not  sensitive  as 
in  the  acute  stage  and  does  not  feel  hot  to  the  examining  finger. 
The  mucous  membrane  is  thickened  and  is  of  a  dark  red  or  bluish 
color;  in  places  it  is  smooth  and  in  others  it  is  roughened  and  the 
discharge  is  thinner  and  less  purulent  than  in  the  acute  stage. 


366  DISEASES  OF  THE  VAGINA 

It  is  to  l)e  remembered  that  the  vagina  may  be  simply  a  canal 
which  conducts  purulent  or  other  fluids  from  the  uterus  or  the 
surrounding  organs  to  the  vulva;  therefore  be  sure  that  the 
inflammatory  process  is  primary  in  the  vagina.  In  the  case  of 
gonococcus  infection,  as  pointed  out  already,  the  process  is  second- 
ary to  infection  in  the  urethra,  Bartholin's  glands,  and  the  cervical 
canal;  consequently  those  situations  should  receive  attention. 

The  special  varieties  of  vaginitis  just  enumerated  should  be 
borne  in  mind  and  their  characteristics  recognized.  Cultures 
and  smears  are  made  from  the  discharges  and  pieces  of  tissue 
removed  for  microscopic  examination  in  all  doubtful  cases. 


DISPLACEMENTS  OF  THE  VAGINA 

In  this  section  we  shall  consider  cystocele,  rectocele,  and  the 
rare  condition  known  as  true  hernia  of  the  vagina. 

CYSTOCELE 

Cystocele  is  a  prolapse  downward  of  the  anterior  wall  of  the 
vagina  together  with  the  base  of  the  bladder.  It  would  appear 
that  in  some  cases  the  muscular  wall  of  the  vagina  has  given  way 
and  the  bladder  wall  in  the  cystocele  is  covered  only  by  vaginal 
mucosa.  If  the  urethra  alone  is  dislocated  downward  the  con- 
dition is  called  urethrocele.  In  this  case  the  urethra  may  be  detected 
as  a  thickened  ridge,  and  passage  of  the  sound  together  with 
palpation  shows  the  situation  of  the  urethra. 

Etiology  and  Frequency. — The  chief  cause  of  cystocele  is  child- 
bearing,  the  anterior  movable  segment  of  the  pelvic  floor,  that 
portion  lying  between  the  arch  of  the  pubes  and  the  uterus  (see 
Chapter  XIII,  Etiology  of  Prolapse,  page  223)  being  dislocated 
and  stretched.  Injuries  of  the  perineum,  actual  tears  of  the 
anterior  vaginal  wall,  and  subinvolution  of  the  vagina  are  con- 
tributory causes.  Rupture  of  the  perineum  and  consequent  lack 
of  support  to  the  anterior  wall  of  the  vagina  is  an  important 
factor  in  the  causation.  Cystocole  is  most  often  met  with  in 
working  women  who  have  less  careful  obstetric  supervision  than 
the  women  of  the  upper  classes,  and  get  on  their  feet  before  involu- 


DISPLACEMENTS   OF  THE   VAGINA 


367 


tion  of  the  uterus,  vagina,  and  perineum  have  been  completed. 
As  injuries  of  the  perineum  and  pelvic  floor  are  the  chief  cause 
of  subinvolution  it  behooves  the  physician  to  diagnose  and  repair 
these  injuries  promptly  and  thus  prevent  the  occurrence  of  cysto- 
cele,  which  may  not  develop  for 
months  or  years  after  the  re- 
ceipt of  the  injuries. 

Symptoms. — The  symptoms 
depend  on  the  extent  of  the 
prolapse.  They  are,  a  sensa- 
tion of  fullness  in  the  orifice  of 
the  vagina,  and  the  feeling  that 
something  projects  in  that  sit- 
uation on  straining,  the  bulg- 
ing cystocele  being  mistaken 
for  uterine  prolapse;  also  drag- 
ging and  weight  in  the  pelvis, 
in  the  case  of  large  cystocele 
and  prolapse,  and  inability  to 
empty  the  bladder  easily.  If 
the  urethra  is  dislocated 
(urethrocele)  there  is  more  or 
less  incontinence  on  coughing, 


FIG.  148.— Cystocele. 


laughing,  and  straining.  There  may  be  residual  urine  in  a  dislo- 
cated bladder  with  consequent  cystitis.  This  is  rare. 

Diagnosis. — There  may  or  may  not  be  evidence  of  bulging  of 
the  anterior  wall  of  the  vagina  when  the  introitus  vaginae  is 
inspected  with  the  patient  in  the  dorsal  position.  Straining  brings 
the  anterior  wall  into  view,  however.  A  curved  sound  introduced 
through  the  urethra  shows  the  situation  of  the  base  of  the  bladder 
as  determined  by  palpation  of  its  tip  under  the  anterior  vaginal 
wall.  The  extent  of  the  prolapse  may  be  estimated  by  examining 
the  patient  in  the  standing  position  and  asking  her  to  strain  while 
the  examination  is  made.  In  the  knee-chest  position  the  cystocele 
disappears.  In  large  cystoceles  the  vaginal  wall  is  thickened  and 
has  the  appearance  of  skin.  In  prolapse  of  the  uterus  it  may  be 
ulcerated. 

Differential  Diagnosis.— AY e  must  distinguish  cystocele  from 
cvst  or  other  tumor  of  the  vagina,  hypertrophy  of  the  bladder 


368 


DISEASES  OF  THE  VAGINA 


wall  in  chronic  cystitis,  sub-urethral  abscess,  and  true  intestinal 
hernia  of  the  vagina.  Tumor  of  the  anterior  vaginal  wall  docs  not 
increase  in  size  or  tension  on  straining  and  coughing,  it  docs  not 
disappear  on  pressure  or  on  putting  the  patient  in  the  knee-chest 
position,  filling  the  bladder  has  no  effect  on  the  size  or  elasticity 
of  the  tumor,  and  palpation  of  a  sound  in  the  bladder  shows  that 
there  is  something  besides  the  walls  of  the  bladder  and  vagina 
between  the  tip  of  the  sound  and  the  examiner's  finger  in  the 
vagina. 

Hypertrophy  of  the  bladder  wall  in  chronic  cystitis  to  the  extent 
of  forming  a  tumor  in  the  vagina  is  rare.  The  diagnosis  of  cystitis 
by  means  of  the  cystoscope  and  examination  of  the  urine,  together 


FIG.  148«. — Diagrammatic  Representation  of  Cystocele. 

with  the  symptoms  of  cystitis,  point  the  way  toward  a  differentia- 
tion. Palpation  of  the  greatly  thickened  bladder  by  the  finger 
in  the  vagina  will  settle  the  diagnosis. 

Sub-urethral  abscess  is  diagnosed  by  placing  a  sound  in  the 
urethra  and  palpating  the  tumor  in  the  vagina  on  the  sound. 
In  this  way  it  will  be  plain  that  the  urethra  is  not  involved  in  the 
tumor.  Besides,  there  are  present  in  the  case  of  the  abscess  symp- 
toms and  signs  of  inflammation,  and  there  is  apt  to  be  a  minute 
opening  of  the  abscess  into  the  urethra  through  which  pus  may 
be  forced  on  pressure. 

Anterior  intestinal  vayinal  hernia  is  a  rare  condition  in  which 


DISPLACEMENTS   OF  THE   VAGINA 


369 


coils  of  small  intestine  occupy  a  sac  formed  by  a  pouch  of  pro- 
lapsed peritoneum  between  the  front  of  the  uterus  and  the  bladder. 
This  pouch  projects  under  the  anterior  vaginal  wall  in  the  same 
situation  as  a  cystocele.  On  pressure  a  true  hernia  disappears 
with  a  gurgling  sound,  it  disappears  when  the  patient  is  in  the 
knee-chest  position,  it  is  soft  and  doughy  to  the  touch,  and  the 
coils  of  intestine- may  be  palpated  between  a  sound  in  the  bladder 
and  a  finger  in  the  vagina,  thus  showing  a  greater  thickness  of 
the  intervening  structures  than  in  the  case  of  cystocele. 


RECTOCELE 

Rectocele  is  a  forward  protrusion  of  the  anterior  rectal  wall 
into  the  vagina,  although  the  name  is  given  to  any  bulging  of  the 
posterior  vaginal  wall,  whether  the  protrusion  contains  the  rectum 
or  not.  It  is  possible  for  the  posterior  vagina  to  become  separated 
from  the  rectal  wall,  because 
of  the  loose  connection  of  the 
two  structures.  As  a  rule  the 
rectal  wall  is  in  the  dislocated 
vagina.  Rectocele  is  one  of 
the  concomitants  of  complete 
uterine  prolapse. 

Etiology  and  Frequency.— 
Rectocele  is  caused  by  rupture 
of  the  perineum  and  pelvic 
floor,  by  consequent  subinvo- 
lution  of  the  vagina,  and  by 
chronic  overdistention  of  the 
rectum  by  feces  and  scybalous 
masses. 

The  firm  support  ordinarily 
given  to  the  anterior  wall  of 
the  rectum  during  defecation, 
due  to  contraction  of  the  levator  ani  muscle  at  this  time,  is  lacking 
because  of  the  injury  of  this  muscle.  Therefore  the  fecal  mass 
covered  by  rectal  and  vaginal  walls  is  pushed  forward  into  the 
vagina.  Constant  straining  accentuates  the  faulty  condition. 
Like  cystocele,  the  development  of  a  rectocele  is  a  matter  of 
24 


FIG.  149. — Rectocele. 


370 


DISEASES  OF  THE   VAGINA 


months  and  years,  and  the  disease  is  frequent  among  the  working 
classes  for  the  same  reason  as  in  the  case  of  cystoccle. 

Symptoms. — The  symptoms  are  a  sense  of  fullness  in,  or  pro- 
trusion from,  the  vulva,  weight  and  dragging  in  the  pelvis,  and 
difficulty  in  defecation.  Sometimes  the  woman  is  obliged  to 
replace  the  rectocele  with  her  fingers  before  she  can  empty  the 
bowel,  and  in  pronounced  cases  of  rectocele  there  is  apt  to  be 
rectal  tenesmus  and  a  feeling  as  if  the  rectum  had  not  been  emptied 
completely. 

Diagnosis. — Bulging  of  the  posterior  vaginal  wall  may  be  visible 


FIG.  149a. — Diagrammatic  Representation  of  Rectocele. 

on  separating  the  labia  when  the  patient  is  in  the  dorsal  position. 
Straining  brings  the  wall  into  view  and  it  recedes  again,  when  the 
effort  is  over.  The  physician,  passing  a  forefinger  through  the 
anus,  hooks  it  forward  into  the  rectocele.  This  makes  positive 
the  diagnosis  and  differentiates  separation  of  the  posterior  vaginal 
wall  from  the  rectum,  from  cases  of  true  rectocele.  We  must 
rule  out  cysts  and  other  tumors  of  the  posterior  vaginal  wall  and 
true  posterior  vaginal  hernia  or  enterocele.  Both  of  these  are 
palpated  between  a  finger  in  the  rectum  and  another  finger  in  the 
vagina.  A  cyst  or  tumor  is  fluctuating  or  hard,  and  is  felt  as  a 
distinct  mass  between  the  two  fingers,  whereas  in  rectocele  the 
rectum  and  vaginal  walls  alone  are  between  the  fingers. 


INJURIES  OF  THE  VAGINA  371 

In  the  case  of  enterocele  the  doughy  feel  of  intestine  with  gur- 
gling on  pressure  is  to  be  made  out,  and,  on  placing  the  patient 
in  the  knee-chest  position  the  tumor  disappears. 

HERNIA  OR  ENTEROCELE 

True  hernia  or  the  descent  of  a  loop  of  intestine  in  a  pouch  of 
peritoneum  either  into  the  recto-vaginal  cellular  tissue  below 
Douglas'  cul-de-sac,  or  into  the  cellular  tissue  between  the  uterus 
and  the  bladder,  is  a  rare  occurrence.  It  is  sufficient  to  note  that 
cases  have  been  reported  and  that  the  diagnosis  is  made  by  pal- 
pating the  tumor  and  eliciting  the  doughy  feel  characteristic  of 
intestine,  by  noting  gurgling  noises  in  the  tumor  when  it  is  pressed 
upon,  and  by  observing  that  the  tumor  increases  in  size  on  straining, 
but  disappears  when  the  patient  is  placed  in  the  knee-chest  position. 
Such  tumors  must  be  differentiated  carefully  from  rectocele, 
cystocele,  or  tumor  of  the  vaginal  wall.  (See  these  sections.) 

In  very  rare  cases  an  enterocele  has  been  known  to  find  its 
way  to  the  vulva.  In  this  situation  it  must  be  distinguished  from 
inguinal  hernia  that  has  reached  the  labium  majus.  Examination 
of  the  external  abdominal  ring  will  show  whether  the  ring  is  free. 
Also  it  is  to  be  differentiated  from  a  cyst  of  Bartholin's  gland  or 
other  tumor  of  the  labium.  In  the  case  of  the  enterocele  it  has  an 
origin  from  above,  has  an  impulse  on  coughing,  and  disappears 
with  the  patient  in  the  knee-chest  position.  A  tumor  of  the  labium 
has  none  of  these  characteristics. 


INJURIES  OF  THE  VAGINA 

Injuries  of  the  vagina  may  be  due  to  (1)  childbearing,  to  too 
rapid  expulsion  of  the  head,  breech,  or  shoulders,  or  to  pressure 
of  the  blades  of  forceps,  (2)  to  coitus,  where  there  is  disproportion 
between  the  size  of  the  penis  and  the  vagina,  and  too  great  violence 
is  used,  (3)  to  unskillful  instrumentation,  and  (4)  to  a  fall  on  a 
sharp  body  such  as  a  picket. 

(i)  Childbearing.— A  majority  of  injuries  due  to  childbearing 
consist  of  lacerations  of  the  perineum,  next  in  frequency  are 
lacerations  of  the  upper  vagina,  due  to  the  extension  of  a  tear  of 
the  cervix  to  the  vagina.  Sometimes  a  circular  laceration  in  the 


372  DISEASES  OF  THE  VAGINA 

upper  vagina  may  separate  the  cervix  partially  or  wholly  from 
the  vagina.  Generally  the  tears  of  the  vagina  are  longitudinal  in 
direction.  On  one  occasion  I  repaired  immediately  after  a  version 
an  extensive  longitudinal  laceration  of  the  anterior  vaginal  wall 
not  involving  the  cervix.  Lacerations  of  the  vagina  are  more  apt 
to  occur  where4  the  vaginal  wall  has  been  narrowed  by  cicatrices 
or  its  elasticity  has  been  impaired  by  disease. 

Lacarations  of  the  Perineum  and  Pelvic  Floor. — By  this  term  is 
meant  not  only  injuries  of  the  perineal  body  so-called, — really  not 
an  anatomical  entity, — but  also  damage  to  the  structures  compos- 
ing the  pelvic  floor.  These  are  the  levatores  ani, — sphincter  vaginae, 
sphincter  ani,  and  transversus  perinei  muscles,  and  the  following 
fascue:  posterior  layers  of  the  triangular  ligament, — called  also 
the  transverse  perineal  septum,  a  strong  mass  of  connective  tissue 
and  elastic  tissue  in  which  the  muscles  are  inserted,  the  anal  fascia, 
the  recto-vesical  fascia,  and  the  deep  superficial  fascia. 

By  conjoined  recto- vaginal  examination  of  a  nullipara  one 
determines  that  the  tissues  between  the  fingers  are  of  the  shape 
roughly  of  a  triangle,  with  its  slightly  convex  base  the  space  on  the 
skin  between  the  anus  and  the  fourchette,  and  its  apex  at  the 
upper  limit  in  the  vagina  of  the  lower  anterior  curve  of  the  S 
formed  by  that  canal  in  its  course  to  the  cervix.  The  tissues  feel 
firm  and  elastic  (the  transverse  perineal  septum)  and  there  is  a 
distinct  convexity  upward  (the  patient  being  in  the  dorsal  position) 
of  the  lower  posterior  vaginal  wall. 

An  attempt  to  evert  the  rectum  through  the  opening  of  the 
vagina  will  encounter  much  resistance  and  cause  pain  to  the 
patient.  If,  now,  the  patient  is  asked  to  strain  it  is  noted  that 
the  anterior  and  posterior  walls  of  the  vagina  already  in  contact 
are  pressed  more  firmly  together  and  that  the  perineum, — the  skin 
surface  between  the  vagina  and  rectum, — bulges  outward,  and 
the  distance  between  anus  and  fourchette  is  increased.  If,  on 
the  contrary,  the  woman  is  told  to  draw  in  the  muscles  it  will  be 
found  that  the  anus  and  the  skin  perineum  are  lifted  inward 
and  upward  toward  the  posterior  surface  of  the  arch  of  the 
pubes. 

By  vaginal  palpation  pressure  directed  backward  and  on  both 
sides  of  the  middle  line  encounters  definite  elastic  resistance  (the 
levator  ani  muscles).  If  the  patient  is  asked  to  contract  the  mus- 


INJURIES   OF  THE   VAGINA 


373 


cles  they  are  felt  to  become  rigid.  The  significance  of  a  laceration 
depends  on  the  number  of  structures  involved  and  on  the  extent 
of  the  injury. 

In  most  first  labors  there  is  some  injury  of  the  fourchette  in  the 
median  line.  These  superficial  tears  are  of  little  practical  impor- 
tance because  they  do  not  involve  the  supporting  structures  of 
the  pelvic  floor.  If  the  structures  composing  the  perineum  are 


FIG.  150. — Diagrammatic  Longitudinal  Median  Section  of  the  Pelvis,  Showing 
Structures  of  the  Pelvic  Floor.     (Dickinson.) 

rigid  and  non-elastic,  as  in  the  case  of  old  primiparse,  the  tear  is  apt 
to  be  deeper  and  therefore  of  more  serious  import. 

Tears  of  the  pelvic  floor  proper  are  of  three  sorts:  (a)  median, 
(6)  lateral  in  one  or  both  sulci,  and  (c)  a  combination  of  these 
two. 

(a)  Median  tears,  if  of  any  considerable  depth,  are  apt  to  involve 
the  sphincter  ani  muscle  to  a  greater  or  less  degree.  To  put  the 
case  a  little  differently,  a  vast  majority  of  the  lacerations  of  the 


374 


DISEASES  OF  THE  VAGINA 


sphincter  ani  are  median  tears.  In  the  case  of  complete  laceration 
of  the  perineum  the  pelvic  floor  proper  is  not  injured  to  the  extent 
that  its  supporting  power  is  lessened,  therefore  we  do  not  expect 
to  find  the  results  of  laceration  of  the  pelvic  floor  in  the  form  of 
cystocele,  retroversion,  and  prolapse. 

Partial  or  complete  loss  of  control  over  the  bowels  is  to  be  ex- 
pected after  laceration  of  the  sphincter  ani.  If  only  a  portion  of 
the  fibers  of  the  sphincter  are  injured  the  patient  may  be  able  to 
control  her  bowels  if  they  arc  constipated,  but  not  if  they  are  loose; 
or  the  retentive  power  over  gas  may  be  lost. 

Complete  Laceration. — Suppose  the  laceration  is  complete. 
Inspection  shows  a  gaping  vulva  with  the  retracted  ends  of  the 


FIG.  151. — Complete  Median  Laceration  of  the  Perineum, 
not   Injured.    (Gilliam.) 


Levator  Ani  Muscles 


sphincter  ani  muscle  showing  as  a  minute  dimple  on  each  side 
of  the  anus  at 'the  ends  of  the  contracted,  crescentic  muscle.  The 
recto-vaginal  septum,  when  not  extensively  torn,  stretches  above 
as  a  tense  band  across  the  open  anus,  in  which  the  bright  red 
corrugated  mucosa  of  the  rectum  is  seen.  Unless  the  levator  ani 
has  been  injured,  the  walls  of  the  upper  vagina  are  in  contact. 
If  the  laceration  has  not  been  complete  a  finger  inserted  into  the 
anus  estimates  the  amount  of  damage  to  the  sphincter  by  noting 
the  strength  with  which  it  grasps  the  finger. 

(b~)  and  (c).     Lateral  tears  in  the  sulci  are  the  common  forms 


INJURIES   OF  THE   VAGINA 


375 


of  injury  to  the  pelvic  floor.  They  are  the  important  ones  from 
the  point  of  view  of  the  dislocation  and  diseases  of  the  pelvic 
organs  which  result  if  they  are  not  repaired. 

The  lateral  tears  injure  the  levator  ani  muscle.  After  the  injury 
the  muscle  ends  contract  and  carry  with  them  the  torn  fasciae; 
some  of  the  injured  structures  are  replaced  by  connective  tissue, 
and,  in  the  case  of  tears  reaching  the  surface,  by  cicatricial  tissue. 
In  the  course  of  many  years  there  may  be  marked  atrophy  of  all 
the  structures  composing  the  pelvic  floor.  The  exact  kind  of 
deformity  that  results  in  any  given  case  is  determined  by  the 


FIG.  152. — Perineum  Lacerated  in  Both  Sulci.     Levator  Ani  Muscles  Injured. 

(Gilliam.) 

structures  involved  and  the  time  which  has  elapsed  since  the 
receipt  of  the  injury.  Sundering  the  transverse  perineal  septum 
permits  the  trans  versus  perinei  muscles  to  contract  and  draw 
the  edges  of  a  wound  to  both  sides  of  the  vulva.  At  an  exami- 
nation of  a  fresh  tear  in  the  hours  following  delivery  it  is  possible 
to  get  a  fairly  accurate  idea  of  the  structures  involved,  although 
the  swelling  and  distortion  of  the  tissues  at  this  time  render  the 
determination  not  easy.  By  separating  the  labia  and  sponging 


376  DISEASES  OF  THE  VAGINA 

off  the  blood,  the  difference  between  the  shining  vaginal  mucosa 
and  the  oozing  raw  tissue  becomes  apparent.  The  anterior  vaginal 
wall  should  be  held  up  against  the  pubes  and  the  tears  traced  to 
their  farthest  limits.  With  a  finger  in  the  rectum  the  upper  por- 
tions may  be  brought  better  into  view.  A  good  light  and  the 
patient  on  a  table  or  on  an  ironing  board  on  the  edge  of  the  bed 
are  essentials  to  an  exact  diagnosis.  After  an  interval  of  months 
and  years  we  can  not  say  exactly  what  has  occurred  at  the  time 
of  injury.  Dissection  on  the  living,  in  the  course  of  an  operation 
undertaken  for  the  purpose  of  repair,  will  not  give  us  this  informa- 
tion because  of  the  abundant  blood  supply  of  the  parts  involved. 
Inspection  of  an  old  laceration  in  the  sulcus  shows  a  gaping  vulva, 
vaginal  walls  apart,  perhaps  cystocele,  rectocele,  or  prolapse,  the 
perineum  is  flat  and  longer  than  normal  because  the  rectum  is 
displaced  backward.  When  the  patient  strains  the  vaginal  walls 
roll  down  instead  of  holding  closer  together,  and  the  perineum 
between  the  fourchette  and  anus,  instead  of  bulging,  is  con- 
cave. Palpation  shows  a  groove  in  the  sulcus  and  a  lack  of  hard- 
ness here  when  the  patient  contracts  the  muscles  of  the  pelvic 
floor.  The  perineal  septum  is  always  more  or  less  injured  in 
these  cases,  and  palpation  of  the  perineum  with  one  finger  in  the 
vagina  and  the  other  in  the  rectum  will  make  manifest  that  the 
convex  summit  of  the  perineal  body,  the  top  of  the  anterior  S 
curve  of  the  lower  vagina,  has  disappeared  and  in  its  place  is  a 
depression.  In  many  cases  very  little  injury  is  apparent  when  the 
vulva  is  inspected  because  the  skin  has  not  been  severed.  The 
physician  should  be  on  the  lookout  for  the  "skin  perineum"  and 
not  be  deceived  by  it.  By  hooking  a  finger  into  the  vagina  the 
absence  of  the  firm  convex  surface  of  the  perineum  will  be  appar- 
ent at  once.  A  common  form  of  laceration  is  a  tear  in  one  sulcus 
together  with  a  tear  in  the  median  line. 

By  the  former  we  assume  that  the  levator  ani  is  injured  and  by 
the  latter  the  transverse  perineal  septum.  Often  both  sulci  are 
affected  and  there  is  also  a  tear  in  the  median  line  below.  Too 
much  can  not  be  said  of  the  importance  of  making  an  exact  diag- 
nosis of  the  situation  of  the  tear  in  every  case  of  rupture  of  the 
pelvic  floor,  for  in  this  way  only  can  repair  be  intelligently  carried 
out. 

(2)  Injuries  due  to  coitus  arc  not  frequent.    Sometimes  the  first 


FOREIGN  BODIES  IN  THE  VAGINA  377 

coitus  causes  a  laceration  of  the  hymen  which  extends  to  the  vagina 
and  there  may  be  serious  hemorrhage.  Rape  has  caused  severe 
and  fatal  injury  of  the  vagina  in  children  and  also  in  women.  In 
willing  coitus  whenever  there  is  a  large  penis  and  a  small  vagina 
injury  may  occur  if  force  is  used. 

(3)  Injuries  due  to  unskillful  instrumentation    are    not  very  un- 
common.    The  violence  is  done  sometimes  by  the  patient  intro- 
ducing sharp  instruments  into  the  vagina  in  an  effort  to  produce 
abortion,  and  at  others  by  the  ignorant  abortionist,  also  the  un- 
skillful use  of  the  obstetric  forceps  or  other  instruments  may  cause 
laceration,  often  of  serious  import. 

(4)  Falls  on  sharp  bodies,  such  as  the  picket  of  a  fence    or  the 
handle  of  a  pitchfork,  have  produced  extensive  and  even  fatal  in- 
juries. 

Hematoma  of  the  vagina  is  a  rare  condition.  It  occurs  both  as  a 
result  of  trauma  and  following  labor,  the  latter  being  by  far  the 
more  frequent  cause.  There  is  a  collection  of  blood  just  under  the 
mucous  membrane  and  the  tumor  is  dark  in  color  and  fluctuates. 


FOREIGN  BODIES  IN  THE  VAGINA 

Little  girls  may  introduce  foreign  bodies  in  the  vagina,  just  as  in 
the  other  accessible  cavities  of  the  body,  from  a  spirit  of  inquisi- 
tiveness.  Thus  pebbles,  seeds,  fruit-stones,  pencils,  hairpins,  and 
other  objects  have  been  removed  from  the  vaginae  of  little  girls. 
Older  girls  and  women,  especially  the  sexually  perverted,  have 
introduced  the  ends  of  candles,  pencils,  and  other  things  for  pur- 
poses of  masturbation.  Spools,  rubber  balls,  sponges,  pieces  of 
cotton,  and  many  other  substances  have  been  taken  from  vagina?  in 
which  they  had  been  placed  in  the  hope  of  preventing  conception. 

The  vagina  has  served  as  a  repository  for  smuggled  and  stolen 
property,  such  as  jewelry,  gems,  and  banknotes,  and,  in  the  case  of 
the  feeble-minded,  a  legion  of  strange  articles  have  been  secreted 
there.  The  foreign  body  most  often  found  in  the  vagina  is  a  neg- 
lected or  forgotten  pessary.  As  is  well  known,  a  hard-rubber 
pessary  becomes  incrusted  with  lime  salts  as  soon  as  its  polish  is 
gone.  The  roughened  surface  chafes  the  mucous  membrane  until  it 
ulcerates.  Soft-rubber  pessaries  irritate  the  vagina  more  than  the 


378  DISEASES  OF  THE  VAGINA 

hard-rubber  variety,  as  a  rule,  but  not  being  so  firm  do  not  cut  so 
far  into  the  tissues.  Pessaries  have  been  retained  for  a  long  series 
of  years  in  reported  cases,  and  sometimes  with  resulting  stenosis  of 
the  vagina.  Sometimes  a  vesico- vaginal  or  a  recto- vaginal  fistula 
is  caused  in  this  way.  Pin  worms  and  round  worms  may  inhabit 
the  vagina.  There  is  a  foul  discharge  from  the  vagina  if  ulccration 
is  present.  The  diagnosis  of  a  foreign  body  is  an  easy  matter  when 
digital  and  speculum  examination  are  made,  attention  having  been 
attracted  by  the  vaginal  discharge. 

Gas  in  the  Vagina  (Garrulity  of  the  Vagina.) — An  accumulation  of 
gas  in  the  vagina  that  is  expelled  with  a  noise  on  straining  or  moving 
the  body  quickly  from  one  position  to  another  is  a  not  very  rare 
condition.  Every  gynecologist  of  experience  has  seen  many  cases. 
In  the  past  it  has  been  thought  that  such  a  condition  was  due  ex- 
clusively to  injuries  to  the  pelvic  floor,  so  that  in  certain  positions 
of  the  body,  as  on  the  side,  air  entered,  to  be  expelled  later  when 
the  woman  assumed  the  upright  position.  Although  such  a  cause 
may  be  operative  in  some  cases,  the  recent  investigations  of  Klein- 
wiichter,  Taussig,  and  Veit  ("Handbuch  der  Gynakologie,"  zweite 
Aufl.,  Bd.  Ill,  page  201)  go  to  prove  that  the  accumulation  of  gas 
in  the  vagina,  a  condition  most  often  found  in  the  pucrperium,  is 
due  to  a  gas-forming  bacterium.  The  disease  is  thought  to  be  allied 
to  vaginitis  emphysematosa  (see  page  364)  and  has  been  classed  by 
Veit  as  among  the  inflammations  of  the  vagina. 

When  the  disease  is  due  to  injury  of  the  pelvic  floor  with  subin- 
volution  coupled  with  weakening  of  the  abdominal  walls,  the  diag- 
nosis is  not  so  difficult.  If  these  conditions  do  not  obtain,  and  it  is 
due  to  a  gas-forming  organism,  drying  the  vagina  and  packing  it 
with  dry  tampons  on  which  boric  acid  powder  has  been  dusted 
will  kill  the  organism  and  thus  confirm  the  diagnosis.  We  must 
rule  out  recto-vaginal  fistuhc  in  these  cases,  for  gas  in  the  vagina 
may  come  from  the  rectum. 

VAGINISMUS 

Vaginismus  may  be  regarded  as  a  symptom  rather  than  a  disease. 
It  consists  of  a  hyperesthctic  condition  of  the  orifice  of  the  vagina 
and  is  characterized  by  spasmodic  and  painful  contractions  of  the 
levator  ani  and  constrictor  vagime  muscles.  Sometimes  the  irri- 


NEW  GROWTHS  OF  THE  VAGINA  379 

lability  extends  to  the  muscles  of  the  thighs  or  other  sets  of  muscles 
in  the  neighborhood  of  the  vulva. 

Vaginismus  is  a  rare  condition  found,  as  a  rule,  in  young,  neurotic 
women  and  in  the  newly  married.  It  may  occur,  however,  in 
women  who  have  borne  children.  It  may  be  dependent  on  a  local 
lesion,  such  as  urethral  caruncle  or  inflammation  of  the  vulva. 
Masturbation,  by  overstimulation  of  the  sexual  organs,  causes 
vaginismus  in  some  instances.  Ineffectual  attempts  at  coitus  pro- 
duce in  time  erosions  at  the  introitus  and  nervous  excitability  and 
dread  of  pain.  A  large  penis  and  a  small  vagina  may  cause  tonic 
spasms  of  the  muscles  of  the  pelvic  floor.  Cases  are  on  record  where 
the  penis  has  become  imprisoned  in  the  vagina  by  vaginismus  so 
that  it  was  necessary  to  administer  an  anesthetic  to  the  woman 
before  the  couple  could  be  separated.  The  vagina  may  be  very 
sensitive,  so  that  the  slightest  touch  or  even  taking  a  douche  causes 
contraction  of  the  muscles,  and  a  vaginal  examination  is  impossible 
without  an  anesthetic,  or  it  may  be  caused  only  by  violent  inter- 
course. The  nervous  system  suffers  when  vaginismus  has  existed 
for  any  length  of  time  and  various  nervous  stigmata  may  be 
present.  A  vaginal  examination  will  determine  the  cause  of  the 
condition.  If  necessary  a  second  examination  with  an  anesthetic 
must  be  made.  Vaginismus  is  one  of  the  causes  of  dyspareunia, — 
painful  coitus.  (See  Chapter  X.,  page  146.) 


NEW  GROWTHS  OF  THE  VAGINA 

The  new  growths  of  the  vagina  are:  (1)  cysts,  (2)  myomata,  (3) 
sarcomata,  (4)  carcinomata. 

(i)  Cysts. — Cysts  of  the  vagina  are  the  most  frequent  of  the 
tumors  found  in  this  organ.  As  a  rule,  they  are  between  the  size  of 
a  pea  and  an  English  walnut,  are  single,  and  found  on  the  anterior 
rather  than  on  the  posterior  wall.  Very  large  cysts  may  develop 
in  exceptional  instances,  and  in  such  cases  the  cyst  develops  in  the 
broad  ligament ;  very  rarely  a  series  of  cysts  is  found.  A  cyst  of 
the  vagina  appears  as  a  bluish- white,  rounded  eminence  in  the 
pink  mucous  membrane  of  the  vagina.  It  is  elastic  to  the  feel.  If 
the  cyst  is  situated  superficially  it  projects  more  into  the  lumen  of 
the  vnjnna  and  is  of  a  darker  color  because  of  its  thin  walls;  if  it 


380 


DISEASES  OF  THE  VAGINA 


is  situated  deep  in  the  vaginal  wall  it  projects  less  prominently  and 
is  not  so  dark  in  color. 

Cysts  of  the  vagina  are  due  to  (a)  inclusions  of  epithelial  tissue 
during  operations  for  the  repair  of  lacerations  of  the  perineum, 
or  during  spontaneous  healing  of  such  injuries;  (6)  vaginal  gland 

tissue,  and  (r)  the  remains  of  embryonic 
structures,  such  as  Gartner's  and  Miil- 
ler's  ducts.  The  inclusion  cysts  are 
generally  found  in  the  neighborhood  of 
the  perineum,  in  the  posterior  wall,  low 
down.  These  are  small,  spherical  in 
shape,  have  as  contents  mucus  made 
turbid  by  desquamated  epithelium,  and 
are  lined  with  a  layer  of  stratified 
squamous  epithelium.  Not  much  is 
known  about  the  cysts  which  arise 
from  vaginal  gland  tissue.  They  are 
infrequent  as  compared  with  the  other 
two  varieties,  however.  Cysts  originat- 
ing in  persistent  Gartner's  ducts  are 
comparatively  frequent,  and  are  situ- 
ated in  the  lateral  or  anterior  walls  of 
the  vagina.  These  cysts  are  more  apt 
to  be  cylindrical  in  shape  than  per- 
fectly globular,  corresponding  in  their  long  axis  to  the  axis  of  the 
duct,  are  filled  with  a  clear  straw-colored  fluid,  and  are  lined 
with  cylindrical  epithelium. 

A  persistent  Muller's  duct  has  been  referred  to  in  the  chapter 
on  anomalies.  A  blind  end  of  a  misplaced  ureter  has  been  known 
to  form  a  cyst  of  the  vagina. 

The  diagnosis  offers  little  difficulty.  Cystocele,  urethrocele,  and 
rectocele  must  be  ruled  out,  also  other  tumors  of  the  vagina.  An 
art erio- venous  aneurism  lias  been  mistaken  for  a  cyst  of  the  vagina, 
also  vaginal  hernia,  or  collection  of  blood  in  a  double  vagina.  A 
sound  in  the  urethra  or  bladder  will  assist  in  excluding  urethrocele 
and  cystocele,  and  a  finger  in  the  rectum,  rectocele. 

A  cystocele  or  rectocele  should  increase  in  density  on  straining, 
whereas  a  cyst  docs  not.  A  vaginal  hernia  should  transmit  an 
impulse  on  coughing  and  has  a  characteristic  doughy  feel.  It  dis- 


FIG.  153. — Inclusion  Cyst 
of  Vagina  Occurring  Three 
Years  after  Repair  of  a  Peri- 
neal  Tear.  (Cullen.) 


NEW  GROWTHS  OF  THE  VAGINA 


381 


appears  when  the  patient  is  placed  in  the  knee-chest  position.  An 
aneurism  should  have  a  thrill.  The  characteristics  of  double  vagina 
have  been  described  in  the  section  on  anomalies. 

Echinococcus  cysts  of  the  vagina  are  very  rare  and  are  generally 
due  to  echinococcus  colonies  in  the 
mesometrium     burrowing    in     the 
recto-vaginal  septum. 

(2)  Myomata. — Myomata    or    fi- 
broids   of    the    vagina    are    rare. 
Some  seventy  authentic  cases  have 
been  reported  in  the  literature,  being 
found  in  most  cases  in  women  be- 
tween forty  and  fifty  years  of  age. 
They  occur  as  small,  spherical,  hard, 
nodular  tumors,   seldom  over  two 
inches  in  diameter,  projecting  from 
the  vaginal  wall    into    its    lumen. 
They  are  usually  single,  but  may  be 
multiple  and  are  not  associated  with 
fibroids  of  the  uterus,  although  a 
case  where  both  existed  in  the  same 
patient  has  been  reported  by  Fabri- 
cius    (Zentralblatt  fur    Gynakologie, 
1908,  No.  36,  1191)  and  another  by 
Kelly  and  Cullen  ("Myomata  of  the 

Uterus,"  page  440).  The  tumor  is  sessile  and  has  a  fibrous 
capsule  of  its  own  separating  it  from  the  surrounding  tissues. 

The  etiology  of  these  tumors,  just  as  in  the  case  of  fibroids  of  the 
uterus,  is  unknown.  They  are  apt  to  be  the  seat  of  edematous 
degeneration. 

The  diagnosis  is  generally  easy,  the  fluctuating  character  of  a 
vaginal  cyst  serving  to  distinguish  it  from  a  myoma,  and  in  the 
case  of  sarcoma  and  carcinoma  the  mucous  membrane  covering 
the  tumor  is  involved,  whereas  in  myoma  it  is  not.  The  hard 
character  of  the  tumor  serves  to  distinguish  it  from  cystocele,  rec- 
tocele,  or  hernia. 

(3)  Sarcomata. — Sarcoma  of  the  vagina   is   of   two    sorts,   (a) 
sarcoma  of  the  vagina  in  children,  and  (6)  sarcoma  of  the  vagina 
in  adults. 


FIG.  154. — Cyst  of  Anterior 
Vaginal  Wall  Probably  Due  to 
Occlusion  of  Gartner's  Duct. 
(Cullen.) 


382  DISEASES  OF  THE  VAGINA 

(a)  Sarcoma  oj  the  vagina  in  children  is  of  doubtful  etiology,  but 
has  been  observed  very  soon  after  birth.    It  generally  develops  in 
the  first  year  of  life  and  is  fatal  within  a  year  or  two.    In  one  case 
reported  the  child  lived  to  be  six  years  old.    About  forty  cases  of 
this  disease  are  on  record.     The  disease  is  characterized  by  the 
development  of  vesicle-like  polypi  of  a  dark  red  (hemorrhagic)  and 
pinkish-gray   (translucent)   color,  arranged  in  racemose  clusters. 
In  the  beginning  of  the  disease  the  first  appearance  is  a  polyp,  usually 
attached  to  the  anterior  wall  of  the  vagina.    In  five  out  of  the  six- 
teen of  the  twenty-six  cases  analyzed  by  Starfinger  ("Sarcom  der 
Vagina  bei  Kindern,"   1900)  however,  the  disease  began  on  the 
posterior  wall.     Its  surface  is  smooth  and  it  resembles  a  mucous 
polyp  of  the  uterus.    From  this  polyp  there  develop  in  the  course  of 
time,  weeks  or  months  or  even  years,  proliferations  of  cystic  polypi 
until  they  fill  the  vagina  and  project  through  the  vulva.   The  disease 
is  apt  to  involve  the  bladder  at  an  early  date,  then  the  cervix  and 
uterus,  and  finally  the  peritoneum.    Metastases  are  infrequent,  the 
growth  extending  mostly  by  continuity  and  generally  forward  into 
the  bladder  and  peritoneum  and  not  backward  into  the  rectum. 
Histologically  the  growth  consists  of  round  and  spindle-shaped 
cells,  also  giant  cells  and  striped  muscle  fibers.     The  diagnosis 
before  the  disease  has  progressed  extensively  is  very  difficult.    A 
vaginal  discharge  in  an  infant  should  lead  to  a  speculum  exami- 
nation, a  Kelly  cystoscope  with  a  reflected  light  being  the  best 
instrument  for  this  purpose. 

(b)  Sarcoma  of  the  Vagina  in  Adults. — Fifty-two  cases  of  this 
disease  are  on  record.     It  is  a  disease  of  later  adult  life,  few  of  the 
cases  being  under  forty  years  of  age.     Here,  as  in  the  case  of  the 
child,  the  disease   begins  as  a  polyp  most  commonly,  although 
instances  of  its  starting  as  a  diffuse  infiltration  are  reported.     It 
appears  to  lie  latent  for  a  considerable  time,  just  as  with  the  child. 
The  primary  lesion  may  be  on  either  wall  of  the  vagina,  and  it 
progresses  in  its  development  as  a  ring-like  infiltration  so  that  the 
vagina  is  narrowed,  or  it  grows  as  a  diffuse  tumor  of  one  wall. 
Ulceration  occurs.    The  disease  does  not  often  penetrate  the  vesico- 
vaginal  or  recto-vaginal  septa  or  extend  largely,  but  metastases 
to  other  organs  are  formed  relatively  early.     Ilistologically  the 
tumor  is  made  up  of  small  round  cells,  spindle  cells,  and  giant  cells, 
but  not  striped  muscle  fibers.    Melanotic  sarcoma  has  been  report- 


NEW  GROWTHS  OF  THE  VAGINA  383 

ed  in  three  cases.  The  appearance  of  a  polyp  situated  on  the 
vaginal  wall,  usually  with  a  broad  base  and  of  firm  consistency, 
should  excite  a  suspicion  of  sarcoma.  Microscopic  examination 
of  the  removed  polyp  will  distinguish  sarcoma  from  myoma  or 
carcinoma. 

(4)  Carcinoma  of  the  Vagina. — Carcinoma  of  the  vagina  is  sec- 
ondary to  cancer  of  the  uterus,  in  which  event  it  is  relatively  com- 
mon, or  it  is  primary,  when  it  is  comparatively  rare.  Schwarz 
observed  84  cases  of  primary  cancer  of  the  vagina  among  35,807 
gynecological  patients,  or  something  over  two-tenths  of  one  per 
cent.  It  forms  about  one  per  cent  of  all  carcinomata  of  the  gen- 
erative organs.  Primary  cancer  of  the  vagina  is  a  disease  of  advanced 
life,  but  may  occur  as  early  as  the  twenty-sixth  year;  it  occurs  only 
hi  women  who  have  borne  children  and  is  more  often  found  in  the 
posterior  wall.  When  seen  early  it  is  a  nodule  an  inch  or  an  inch 
and  a  half  in  diameter.  The  edges  are  sharply  defined,  infiltrated, 
and  injected.  The  surface  soon  becomes  necrotic  and  ulcerated 
and  may  exhibit  papillary  elevations.  The  nodule  is  firmly  em- 
bedded in  the  surrounding  tissues  after  the  very  earliest  stages. 
The  disease  extends  extremely  rapidly  both  superficially  and  deeply, 
and  if  the  lower  portion  of  the  vagina  is  infected  the  inguinal  lymph 
glands  are  involved.  The  disease  tends  to  extend  to  the  rectum 
more  often  than  to  the  bladder  and  it  may  reach  to  the  vulva;  it 
originates  in  the  squamous  epithelium  and  has  all  the  character- 
istics of  squamous-celled  cancer  (see  Cancer  of  the  Uterus,  page  267). 

In  getting  a  specimen  of  tissue  for  microscopic  examination  the 
deeper  tissues  must  be  excised  because  the  superficial  portions 
consist  usually  of  inflammatory  products  only.  The  symptoms 
in  the  early  stages  are  bleeding  from  the  vagina,  on  coitus  espe- 
cially, also  a  watery  vaginal  discharge. 

In  making  the  diagnosis  we  must  rule  out  secondary  carcinoma 
of  the  vagina.  This  is  clone  by  discovering  cancer  of  the  cervix, 
cervical  canal,  or  fundus  uteri,  or  cancer  of  the  rectum  or  bladder. 
Carcinoma  in  these  situations  must  be  rigidly  excluded  before  pro- 
nouncing the  disease  primary  in  the  vagina.  Myoma  is  excluded 
by  the  physical  appearances  of  myoma  and  by  the  microscope.  If 
a  primary  cancerous  area  lies  behind  a  stenosis  of  the  vagina  the 
diagnosis  is  more  difficult.  Inflammations  of  the  vagina  with  ul- 
cerations  are  differentiated  bv  the  absence  of  infiltration  under  the 


384  DISEASES  OF  THE  VAGINA 

abccss.  If  an  ulceration  caused  by  an  ill-fitting  or  neglected  pessary 
does  not  heal  rapidly  a  portion  should  be  excised  for  microscopic 
examination. 

There  have  been  reported  a  case  or  two  of  primary  chorioepithe- 
lioma  of  the  vagina,  and  venereal  warts  in  conjunction  with  condy- 
lomata  of  the  vulva  occasionally  occur. 


FISTULA  OF  THE  VAGINA 

An  opening  between  the  vagina  and  the  surrounding  hollow 
viscera  is  called  a  fistula.  Of  such  fistula?  there  are  five  sorts: — 
(1)  Vesico- vaginal,  (2)  Urethro- vaginal,  (3)  Uretero- vaginal,  (4) 
Recto-vaginal,  and  (5)  Entero- vaginal.  The  last  is  extremely 
rare.  For  the  sake  of  completeness  we  must  mention  a  communi- 
cation between  the  vagina  and  a  pelvic  abscess,  or  the  peritoneal 
cavity,  openings  made,  as  in  the  case  of  (5),  fistula  into  the  in- 
testine, in  the  course  of  operations. 

Vaginal  fistulse  are  caused  by  sloughing  of  the  vaginal  walls 
due  to  prolonged  pressure  of  the  child's  head  during  labor,  by- 
injuries  from  obstetric  instruments,  by  ulceration  due  to  pessaries 
and  other  foreign  bodies,  or  by  ulcerations  from  foreign  bodies  in 
the  bladder.  They  result  also  in  the  late  stages  of  carcinoma  of 
the  cervix,  vagina,  rectum,  and  bladder,  and  following  operations, 
especially  hysterectomy.  In  the  last  case  and  also  when  a  vesico- 
vaginal  fistula  has  been  formed  by  operation,  nature  closes  the 
opening,  generally  in  a  short  time. 

Vesico-vaginal  fistula  is  the  most  frequent  of  all  the  forms  of 
vaginal  fistuhr,  although  not  nearly  so  often  met  with  as  in  the 
olden  days  before  the  art  of  obstetrics  had  been  perfected  to  its 
present  high  degree  of  excellence.  The  vaginal  and  bladder  walls 
are  involved  in  varying  extent.  Almost  the  entire  base  of  the 
bladder  may  slough  away,  leaving  the  orifices  of  the  ureters  exposed 
in  the  edge  of  the  fistula,  or  the  opening  between  the  bladder  and 
vagina  may  be  no  larger  than  a  pin's  point.  The  symptoms  arc 
leakage  of  urine  from  the  vagina,  and,  unless  great  care  is  main- 
tained by  the  patient  to  keep  dry,  excoriation,  redness,  and  sore- 
ness of  the  vulva,  perineum,  and  thighs.  The  amount  of  urine  lost 
will  depend  on  the  size  of  the  opening  and  on  the  retentive  power 


FISTULA  OF  THE   VAGINA 


385 


of  the  vagina.  Sometimes  urine  is  retained  in  the  vagina  while  the 
patient  is  recumbent,  the  pelvic  floor  being  uninjured  and  the  in-, 
troitus  small.  Often  when  the  fistula  is  small  the  patient  may  void 
a  portion  of  the  urine  through  the  urethra  and  the  rest  will  escape 
through  the  vagina. 

The  diagnosis  is  made  by  the  history  of  incontinence  and  by  the 
physical  examination.    The  digital  touch,  if  the  fistula  is  large,  will 


FIG.  155. — Scheme  of  the  Different  Sorts  of  Genital  Fistulse,  not  Including 
Fistula-in-Ano.  (Gilliam.)  1.  Urethro- vaginal.  2.  Vesico- vaginal.  3.  Recto- 
vaginal.  4.  Vesico-uterine.  5.  Uretero-vaginal.  6.  Entero-vaginal. 

indicate  the  size  and  situation  of  the  fistula.  The  patient  is  placed 
in  the  Sims  position  and  a  Sims  speculum  introduced.  Inspection 
shows  the  size,  shape,  and  situation  of  the  fistula.  A  sound  or  probe 
passed  through  the  urethra  may  be  made  to  appear  through  the 
opening  in  the  vagina.  In  larger  fistulas  the  bladder  wall  is  apt  to 
be  much  injected  (cystitis)  and  often  incrusted  with  lime  salts. 

25 


386  DISEASES  OF  THE  VAGINA 

These  must  be  removed  gently.  Vesico-vaginal  fistula  gives  a  fine 
opportunity  to  inspect  the  bladder  and  to  catheterize  the  ureters.  If 
the  fistula  is  very  small  and  there  is  doubt  as  to  its  situation,  the 
patient  is  placed  in  the  dorsal  position  and  the  bladder  is  filled  with 
milk  and  water.  Examination  of  the  cleansed  vagina  through  a 
duckbill  speculum  will  show  the  point  at  which  the  white  milk 
leaks  through  the  fistula. 

Uretero-vaginal  fistula  is  detected  in  the  same  manner.  The 
bladder  is  filled  with  milk  and  water  and  it  is  noted  that  clear  urine 
and  no  milk  collects  in  the  vagina;  measure  the  bladder  urine  and 
that  which  gathers  in  the  vagina,  and,  if  the  two  kidneys  are  secret- 
ing an  equal  amount,  it  is  possible,  by  finding  that  the  two  quan- 
tities are  the  same,  to  decide  that  all  the  urine  from  one  ureter 
escapes  into  the  vagina.  The  sense  of  smell  is  a  great  help  in  de- 
tecting the  presence  of  urine,  for  in  some  instances  the  differentia- 
tion of  watery  fluid  coming  out  of  the  uterus  or  the  peritoneal  cavity 
from  urine  is  not  easy.  To  aid  in  distinguishing  urine  in  cases  of 
vaginal  fistula  it  is  sometimes  of  use  to  give  the  patient  five  drops 
of  doubly  distilled  turpentine  on  a  lump  of  sugar  three  times  a 
day.  It  imparts  the  characteristic  odor  of  violets  to  the  urine. 
Mcthylene  blue,  one  to  two  grains  every  four  hours  given  by  the 
mouth,  renders  the  urine  a  bluish-green  color.  The  colored  urine 
may  be  seen  to  escape  from  a  fistula. 

Urethro- vaginal  fistula  is  a  rare  variety  of  fistula  due  to  syphilitic 
or  malignant  ulceration  or  operation  on  the  urethra.  The  opening 
between  the  urethra  and  vagina  is  generally  small  and  is  situated 
in  the  upper  course  of  the  urethra.  There  is  no  incontinence  of 
urine  unless  the  fistula  involves  the  neck  of  the  bladder.  The 
diagnosis  is  made  by  passing  a  probe  into  the  urethra  and  through 
the  fistula.  For  fistula}  involving  the  bladder  and  ureters  see  also 
Chapters  XXIV  and  XXV,  pages  474  and  492. 

Recto-vaginal  fistula  results  in  the  late  stages  of  cancer  of  the 
cervix  and  also  in  the  case  of  neglected  pessaries  and  imperfect 
union  of  a  lacerated  perineum.  Rarely  this  fistula  results  from 
syphilitic  or  tuberculous  lesion  of  the  vagina.  The  opening  is 
generally  small  in  size. 

The  symptoms  arc  the  escape  of  flatus,  and  also  more  or  less  fluid 
feces,  into  the  vagina.  Vaginitis  and  vulvitis  are  apt  to  result  from 
the  irritation  caused  by  the  fecal  matter. 


FISTULA  OF  THE  VAGINA  387 

The  diagnosis  is  founded  on  the  history,  and  on  the  examination. 
The  patient  is  placed  hi  the  dorsal  position  and  the  anterior  vaginal 
wall  raised  by  a  Sims  speculum.  If  the  fistula  can  not  be  seen  a 
probe  is  passed  in  the  most  likely  spots  and  if  it  enters  an  opening 
which  connects  with  the  rectum  its  point  may  be  felt  by  a  finger  in 
that  organ.  Also,  one  may  inject  the  rectum  with  milk  and  water 
and  note  its  escape  into  the  vagina. 

Entero- vaginal  fistula  is  rare.  It  results  generally  from  a  surgical 
operation.  The  presence  of  feces  in  the  vagina,  the  exclusion  of  an 
opening  into  the  rectum  by  means  of  inspection  of  the  rectum 
through  a  proctoscope,  the  character  of  the  fecal  matter  (chyme), 
and  finding  the  opening  of  the  fistula  hi  the  upper  vagina  on  in- 
spection and  probing  with  the  patient  in  Sims  position,  will  establish 
the  diagnosis.  For  fistula-in-ano  see  Chapter  XXVI,  page  516. 


CHAPTER  XXI 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  VULVA 

Anatomy,  p.  388:     Age  changes,  p.  391. 

Congenital  Anomalies,  p.  391:  Malformations  of  the  vulva  as  a  whole, 
p.  391.  Development  of  the  external  genital  organs,  p.  392.  Anomalies, 
p.  393.  Malformations  of  the  clitoris,  p.  393.  Malformations  of  the 
labia  majora,  p.  394.  Malformations  of  the  labia  minora,  p.  394.  Mal- 
formations of  the  hymen,  p.  390.  Imperforate  hymen,  p.  396.  Hennaph- 
roditism,  p.  399. 

Injuries  of  the  vulva,  p.  400. 

Inflammation  of  the  vulva,  p.  402:  Simple  or  catarrhal  vulvitis,  p.  402. 
(itonorrheal  vulvitis,  p.  402.  Diabetic  vulvitis,  p.  403.  Thrush,  p.  403. 
Elephantiasis,  p.  404.  Pruritus  vulvse,  p.  404.  Kraurosis  vulvae,  p.  404. 
Edema  and  gangrene,  p.  40.5.  Varix,  p.  405. 

Venereal  lesions  of  the  vulva,  p.  406;  Chancroids,  p.  406.  Chancre, 
p.  406.  Mucous  patches,  p.  407.  Condylomata,  p.  407.  Gumma,  p.  408. 

Tuberculosis  of  the  vulva,  p.  408. 

Cysts  of  Bartholin's  gland,  p.  408;  Abscess  of  Bartholin's  gland,  p.  409; 
Differential  diagnosis  of  cyst  and  abscess,  p.  412. 

Labial  Hernia,  p.  412. 

Benign  tumors  of  the  vulva,  p.  413. 

Malignant  tumors  of  the  vulva,  p.  414:  Cancer,  p.  414;  Differential 
diagnosis  of  cancer,  p.  415.  Sarcoma,  p.  416. 


ANATOMY 

THE  term  vulva  is  applied  collectively  to  the  structures  often 
called  the  external  genital  organs,  and  includes:  the  mons  veneris, 
the  labia  majora  and  minora,  the  clitoris,  the  vestibule,  and  the 
hymen. 

The  Mons  Veneris. — The1  mons  veneris  is  the  eminence  in  front  of 
the  symphysis  pubis.  It  is  formed  by  a  collection  of  subcutaneous 
fat  and  is  covered  with  coarse  hair,  generally  of  the  same  color  as 
the  hair  of  the  head.  The  upper  limit  of  the  hair  is  a  horizontal 
line,  differing  from  the  male  pubic  hair,  which  is  continued  up- 
ward along  the  linea  alba  iu  a  V  shape.  Below,  the  hair  is  con- 
tinuous witli  the  hair  on  the  outer  surfaces  of  the  labia  majora. 

The  Labia  Majora. — These  are  two  thick,  parallel  folds  of  skin 

388 


ANATOMY  389 

extending  from  the  mons  veneris  nearly  to  the  anus.  They  are 
wider  above  and  grow  thinner  as  they  approach  the  perineum 
where  they  are  lost.  Each  fold  is  called  a  labium  majus  and  the 
opening  where  the  two  meet  in  the  middle  line  is  called  the  pu- 
dendal  slit  (rima  pudendi).  The  posterior  limit  of  the  slit  is  a 
transverse  cutaneous  fold  called  the  fourchette,  the  depression 
between  this  and  the  base  of  the  hymen  being  the  fossa  navicularis. 


FIG.  156. — Diagram  of  the  Vulva.     (Dickinson.) 

The  labia  majora  are  pigmented  more  than  the  surrounding  skin 
and  the  outer  surfaces  contain  sebaceous  glands  and  are  covered 
with  more  or  less  hair,  the  hair  becoming  scanty  and  short  to- 
ward the  posterior  parts.  The  inner  ^surfaces  of  the  labia  majora 
are  smooth,  and  the  thin  skin  covering  them  resembles  mucous 
membrane  in  the  virgin,  but  is  harder  in  the  parous  woman.  The 
outer  ends  of  the  round  ligaments  become  lost  in  the  upper  por- 


390  DISEASES  OF  THE  VULVA 

tions  of  the  labia  majora,  which  are  made  up  of  fat  and  connec- 
tive tissue. 

The  Labia  Minora,  or  Nymphae. — These  are  two  thin,  pink,  deli- 
cate folds  of  skin  extending  from  the  frenum  of  the  clitoris  above, 
downward  to  be  lost  on  the  inner  surfaces  of  the  labia  majora  at 
about  the  level  of  the  opening  of  the  vagina.  They  are  developed 
from  the  margins  of  the  genital  cleft.  They  have  no  hairs  but 
abundant  sebaceous  glands.  Each  fold  is  a  labium  minus,  and 
the  two  labia  may  be  asymmetrical.  In  the  virgin  the  lesser  labia 
are  entirely  covered  by  the  greater  labia,  but  under  abnormal 
conditions  the  nympho?  may  project  beyond  the  labia  majora, 
and  in  this  case  they  are  pigmented. 

The  Clitoris. — This  is  a  rudimentary  penis  developed  from  the 
genital  eminence,  but  it  is  without  a  urethra  traversing  it  (see  Fig. 
157).  It  is  situated  between  the  labia  majora  and  is  concealed  by 
the  upper  portions  of  these  structures,  it  is  about  an  inch  and  a 
quarter  long,  and  arises  from  the  pubic  arch  by  two  crura,  which 
unite  to  form  the  body  of  the  clitoris.  At  its  tip  is  a  glans,  which  is 
covered  partially  or  wholly  by  a  prepuce,  that,  coming  from  above 
and  partially  encircling  the  glans,  is  prolonged  downward  into  the 
labia  minora.  The  clitoris  is  made  up  of  erectile  tissue  and  the 
glans  is  covered  by  a  very  sensitive  epithelium.  At  the  base  of  the 
glans  are  sebaceous  glands  which  secrete  smegma. 

The  Vestibule. — The  space  between  the  clitoris  above,  the  en- 
trance of  the  vagina  below,  and  the  nymphae  on  the  sides  is  the 
vestibule.  It  is  developed  from  the  urogenital  sinus,  is,  roughly, 
triangular  in  shape,  and  is  pierced  in  its  centre  by  the  external 
orifice  of  the  urethra,  (meatus  urinarius)  which  presents  a  longi- 
tudinal slit  closed  by  two  little  lips  (labia  urethra)  which  form  a 
slight  elevation  above  the  surface  of  the  vestibule. 

The  Hymen. — This  is  a  thin,  circular,  white  or  light  pink,  per- 
forated membrane  which  separates  the  vulva  from  the  vagina. 
It  is  made  up  of  connective  tissue  and  elastic  fibers  and  is  covered 
on  both  sides  with  stratified  epithelium.  Its  shape,  thickness, 
and  even  its  situation  vary  in  different  cases.  The  opening  into 
the  vagina  (introitus  vagina1)  is  generally  in  the  anterior  part; 
it  may  be  ring-shaped  (annular),  admitting  the  tip  of  the  forefinger; 
this  is  the  commonest  condition,  or  it  may  be  cribriform,  fimbriate, 
horseshoe-shaped,  septate  or  linear.  The  tissues  of  the  hymen 


CONGENITAL  ANOMALIES  391 

may  be  tough  and  resistant,  though  generally  friable  and  torn  with 
the  first  coitus  or  even  by  vaginal  examination,  always  by  parturi- 
tion. The  remains  of  the  torn  hymen  are  called  carunculae  myrti- 
formes.  In  the  infant  and  embryo  the  hymen  projects  forward 
into  the  cleft  between  the  labia  in  the  form  of  two  apposed  longi- 
tudinal lips.  (Sec  Figs.  163  to  170.) 

The  Glands  of  Bartholin. — These  glands  furnish  a  clear,  glairy,  lu- 
bricating mucus  for  coitus  and  for  the  delivery  of  the  child  during 
labor.  They  are  two  in  number,  each  is  about  the  size  of  a  large 
pea  and  is  situated  at  the  side  of  the  posterior  part  of  the  vaginal 
canal  in  the  sphincter  vaginae  muscle.  The  opening  of  the  canal 
of  the  gland  is  a  minute  pin-point  hole  to  be  found  in  the  posterior 
portion  of  the  inner  surface  of  the  labium  majus.  In  women  who 
have  borne  children  it  is  just  outside  the  last  and  uppermost  car- 
uncula  myrtiformis. 

AGE  CHANGES 

Infancy. — In  infancy  there  is  no  visible  hair  on  the  mons,  and 
the  labia  majora  are  rounded  and  firm,  the  labia  minora  projecting 
between  them  as  slightly  elevated,  pink  folds.  (See  Fig.  203.) 

Puberty. — At  puberty  hair  grows  on  the  mons  and  the  outer 
surfaces  of  the  labia  majora,  the  latter  becoming  pigmented  and 
increasing  in  size  so  that  they  conceal  the  nymphae.  The  nympha3 
may  grow  larger  after  puberty,  and  if  they  do,  the  exposed  parts 
become  pigmented  and  of  coarser  texture.  Enlargement  of  the 
nymphse  has  been  ascribed  to  masturbation,  and  it  is  likely  that 
such  is  sometimes  the  case,  though  this  is  not  the  only  cause. 

Old  Age. — The  hair  on  the  mons  and  labia  majora  becomes 
gray  and  is  shed  soon  after  the  hair  of  the  head.  After  the  meno- 
pause the  mons  loses  its  fat  gradually  and  the  labia  shrink  so  that 
in  old  age  the  orifice  of  the  vulva  gapes.  The  hymen  if  unbroken 
shrinks,  and  the  mtroitus  vaginse  is  narrowed  in  any  event. 

CONGENITAL  ANOMALIES 

Malforations  of  the  Vulva  as  a  Whole. — True  congenital  anom- 
alies of  the  vulva,  such  as  complete  atresia  of  the  vulva,  are  very 
rare  and  occur  for  the  most  part  in  non-viable  fetuses.  There  are 


392 


DISEASES  OF  THE  VULVA 


on  record,  however,  one  case  of  double  vulva  in  an  adult,  and  many 
cases  of  infantile  vulva  where  the  labia  majora  and  minora  were 
small  and  flat,  the  introitus  narrow,  and  the  mons  veneris  not 
prominent  and  poorly  provided  with  hair.  Such  a  condition  is 
usually  associated  with  poorly  developed  general  physique.  Pre- 
cocious development  of  the  vulva  is  found  sometimes  in  conjunction 
with  precocious  menstruation  in  very  young  children.  In  these 
eases  the  breasts  also  show  abnormal  development.  In  the  chapter 
on  diseases  of  the  vagina,  page  356,  I  have  referred  to  the  not  in- 
frequent occurrence  of  a  normal  vulva  and  normal  body  form 


FIG.  157. — The  External  Genital  Organs  at  the  Beginning  of  the  Third  Month 
of  Fetal  Life.     (After  Keibel.) 

associated  with  a  rudimentary  uterus  and  vagina.  An  apprecia- 
tion of  the  steps  in  the  development  of  the  several  parts  of  the 
urogenital  system  is  a  necessity  for  the  proper  understanding  of 
the  different  congenital  malformations  of  the  external  genitals. 

Development  of  the  External  Genital  Organs. — At  the  end  of  the 
first  month  of  intra-utcrine  existence  there  is  developed  in  the 
outer  surface  of  the  caudal  region  of  the  embryo  a  depression  in  the 
skin  (Fig.  158),  which  grows  deeper  until  it  reaches  the1  allantois 
and  rectum  to  form  the  cloaca  (Fig.  159).  About  this  time  ap- 
pears the  genital  eminence  above  the  cloaca,  flanked  on  each  side 
by  a  fold  of  skin.  The  genital  eminence  in  the  female  becomes 
later  the  clitoris,  and  the  folds  of  skin  the  labia  majora,  the  nymphie 
being  developed  on  their  inner  surfaces.  (See  Fig.  157.)  Figure 


CONGENITAL  ANOMALIES  393 

160  shows  the  differentiation  of  the  bladder  and  rectum  from 
the  allantois  and  hind  gut  respectively,  and  the  beginning  of  the 
formation  of  the  perineum  by  the  downward  extension  of  the 
perineal  septum  between  the  rectum  and  the  urogenital  sinus, 
which  has  been  formed  by  a  union  of  the  ducts  of  Miiller  and  the 
cloaca.  The  proctodeum,  the  posterior  portion  of  the  invagination 
of  the  skin  that  is  to  form  the  anus,  is  now  differentiated.  In 
Fig.  161  the  urethra  has  been  formed  and  a  septum  divides  the 
urinary  from  the  genital  tract.  Figure  162  (at  about  the  end  of 
the  fourth  month)  shows  the  vagina,  although  not  yet  with  a  canal, 
developed  from  the  ducts  of  Miiller  and  separated  by  the  hymen 
from  the  vulva.  The  perineum  has  its  mature  shape  and  the  anus 
now  opens  backward.  The  vestibule,  the  clitoris,  and  both  sets  of 
labia  are  already  formed,  although  they  do  not  assume  their  final 
shape  until  the  fifth  or  sixth  month.  The  external  genital  organs 
are  at  birth  much  more  completely  developed  than  the  internal 
organs,  which  remain  in  a  more  or  less  rudimentary  condition  until 
the  child  is  eight  or  ten  years  old. 

Anomalies. — Persistence  of  the  Urogenital  Sinus. — This  is  most 
often  met  with  as  an  opening  of  the  anus  into  the  vagina,  "anus 
vaginalis"  so  called,  in  which  there  is  incontinence  of  feces  because 
of  the  absence  of  the  sphincter  ani  muscle.  There  is  met  with  rarely 
a  hypospadias,  or  a  connection  of  the  urethra  with  the  vagina  high 
up,  the  vestibular  canal  being  long.  Another  form  of  hypospadias, 
also  rare,  is  the  condition  where  there  is  no  urethra  and  the  bladder 
opens  directly  into  the  vestibular  canal.  In  these  cases  there  is  of 
necessity  incontinence  of  urine  and  the  bladder  opening  can  be 
seen  in  the  anterior  wall  of  the  vagina. 

Occasionally  a  case  of  persistent  cloaca  is  met  with,  the  perineal 
septum  and  the  sphincter  ani  not  being  developed.  Incontinence 
of  feces  exists  in  such  cases. 

Malformations  of  the  Clitoris. — The  clitoris  may  be  absent,  it  may 
be  small,  it  ma}'  be  hypertrophied,  it  may  be  cleft,  as  in  epispadias, 
or  the  prepuce  may  be  adherent.  Absence  of  the  clitoris  is  an 
extremely  rare  occurrence,  and  so  is  cleavage  of  the  clitoris,  but 
the  organ  is  found  very  small  not  infrequently,  and  large  quite  com- 
monly. Sometimes  the  clitoris  attains  the  size  of  a  small  puerile 
penis.  Such  a  condition  has  no  clinical  significance  and  requires  no 
treatment  unless  it  interferes  with  coitus, — an  unusual  happening. 


394  DISEASES  OF  THE  VULVA 

An  adherent  prepuce,  on  the  other  hand,  may  be  the  source  of 
sexual  irritation  and  conduce  to  masturbation,  and  in  children 
may  be  the  cause  of  enuresis,  some  writers  even  attributing  the 
existence  of  symptoms  of  grave  derangement  of  the  general  ner- 
vous system  to  this  as  a  cause.  All  women  who  apply  for  gyne- 
cological treatment  should  be  examined  with  reference  to  the 
adhesions  of  the  prepuce.  The  prepuce  should  be  pushed  upward 
with  two  fingers  until  the  glans  can  be  distinguished.  By  the  use 
of  gentle  pressure,  aided  if  necessary  by  the  flat  end  of  a  surgical 
probe,  the  prepuce  may  be  separated  from  the  glans.  Hard,  white 
specks  of  retained  smegma  not  larger  than  a  pin's  point  are  gen- 
erally found  under  the  adherent  prepuce.  Some  authors  maintain 
that  adhesion  is  a  condition  normal  to  the  prepuce  in  both  sexes. 
The  number  that  are  found  to  be  adherent  in  girls  and  women,  if 
every  case  coming  under  observation  is  examined  for  this  con- 
dition, has  been  surprisingly  large  in  my  experience,  and  my  own 
view  is  that  adhesion  of  the  prepuce  in  the  girl  and  woman  plays 
a  much  less  important  role  in  the  causation  of  symptoms  than  in 
the  boy  and  man. 

Malformations  of  the  Labia  Majora. — The  following  malformations 
have  been  described,  although  all  must  be  regarded  as  extremely 
rare.  Absence  of  the  labia,  rudimentary  labia,  multiple  labia, 
hypertrophy  of  the  labia,  and  adhesions  of  the  labia.  The  only 
ones  that  require  comment  are  multiple  and  adherent  labia.  The 
former  consists  of  longitudinal  division  of  the  labia  into  several 
folds  of  skin  instead  of  one,  and  the  latter  is  a  part  of  apparent 
vulvar  atresia.  If  the  closure  is  complete  the  child  is  non-viable. 
Generally  there  is  a  small  opening  anteriorly  through  which  mic- 
turition takes  place. 

Malformations  of  the  Labia  Minora. — The  same  malformations 
as  in  the  case  of  the  labia  majora  have  been  met  with.  The  two 
that  need  description  are  hypertrophy  of  the  labia  and  adherent 
labia.  Hypertrophy  of  the  nymplice  is  by  no  means  rare.  It  reaches 
a  stage  of  extreme  development  in  the  "Hottentot  apron/'  so- 
called,  in  which  the  labia  extend  downward  some  seven  or  eight 
inches  between  the  thighs.  This  condition  is  unknown  among  the 
women  of  civilized  races.  A  moderate  degree  of  hypertrophy  is 
not  uncommon  and  is  of  no  importance  unless  it  interferes  with 
coitus.  Adherent  labia  represent  inflammatory  affections  during 


in  s/r//7 

FIG.  158.  — The  Allantois,  the 
Hindgut,  Mailer's  Duct  and  the 
Depression  in  the  Skin. 


C7oac<x 


FIG.  159. — The  Depression  in 
the  Skin  Has  United  with  the  Al- 
lantois and  Hindgut  to  Form  the 
Cloaca. 


FIG.  160. —The  Bladder  Is 
Formed,  also  the  Beginning  of  the 
Urethra  and  the  Vagina,  Both 
Opening  into  the  Urogenital  Sinus. 
The  Rectum  opens  Separately 
into  the  Proctodeum. 


'4/M/S 


FIG.  161.  — The  Urethra  is 
further  Developed,  the  Opening 
of  the  Vagina  Reaches  nearer  the 
Vulva,  and  the  Perineum  Is 
Formed. 


Vestibule! 


nn&urn 


FIG.  162. — Complete  Development.  The  Urogenital  Sinus  Has  Be- 
come the  Vestibule.  The  Hymen  nearly  Closes  the  Opening  of  the  Vagina, 
which  Has  Become  Enlarged.  The  Rectum  is  more  Capacious  and  the 
Anus  Opens  Backward  Posterior  to  the  fully  Developed  Perineum. 


FIGS.  158-162. — FIVE  DIAGRAMS  OF  LONGITUDINAL  MEDIAN  SECTIONS  OF 
EMBRYOS,  ILLUSTRATING  THE  STAGES  OF  DEVELOPMENT  OF  THE  GENITAL 
ORGANS.  (After  Schroeder.)  395 


396  DISEASES  OF  THE  VULVA 

fetal  or  infantile  life.  The  union  is  generally  incomplete  and 
there  is  an  opening  through  which  urine  can  escape.  Imme- 
diate division  of  the  two  labia  is  demanded  if  there  is  no  open- 
ing when  a  child  with  this  deformity  is  born,  otherwise  it  is 
non-viable. 

Malformations  of  the  Hymen. — Authorities  are  divided  as  to  the 
structures  from  which  the  hymen  is  developed.  Pozzi's  view  of 
its  development  ("Traite  de  Gynecologic,"  quat.  edit'n,  p.  1383) 
seems  as  near  the  facts  as  any.  It  is  that  the  hymen  is  developed 
in  the  fifth  month  from  both  the  vagina  above,  after  fusion  of 
the  Miillerian  ducts,  and  from  the  vestibular  canal, — a  vestige 
of  the  urogenital  sinus, — below.  Gellhorn  (Amer.  Jour.  Obstet., 
Aug.,  1904,  p.  145),  who  has  studied  this  question  most  carefully, 
thinks  that  the  indications  point  to  the  hymen  being  derived  from 
the  Miillerian  ducts  exclusively. 

The  hymen  has  never  been  found  absent  by  competent  observers. 
As  has  been  stated  in  describing  the  anatomy,  the  form  of  the  hy- 
men varies  much  in  different  individuals,  also  its  thickness.  Of 
the  different  forms  in  which  the  hymen  is  found,  the  fimbriate  or, 
denticulate,  the  septate,  the  cribriform,  the  annular,  the  linear  and 
the  crescent,  the  annular  and  crescent-shaped  hymens  are  the  most 
common.  The  hymen  may  be  so  tough  and  resistant  that  it  is  not 
ruptured  by  attempts  at  sexual  intercourse,  on  the  other  hand  it 
may  be  so  dilatable  that  it  stretches  to  accommodate  the  penis  with- 
out tearing.  The  rule  is  that  it  is  generally  torn  by  intercourse,  and 
always  by  parturition.  Cysts  and  solid  tumors  of  the  hymen  have 
been  described,  but  they  are  excessively  rare. 

Imperforate  Hymen. — The  opening  in  the  hymen  may  be  ex- 
tremely minute  and  yet  pregnancy  may  ensue.  A  case  has  been 
recorded  by  H.  L.  Horton  (Boston  Med.  and  Surg.  Jour.,  vol.  82, 
p.  33)  of  a  patient  who  was  in  labor  with  a  hymeneal  opening 
measuring  only  one-sixteenth  of  an  inch  in  diameter.  From  the 
most  recent  researches  the  view  has  gained  ground  that  imper- 
f orate  hymen  is  a  misnomer,  the  condition  being  one  really  of 
atresia  of  the  vagina,  for  in  many  of  the  cases  recorded  after  the 
liberation  of  retained  menses  a  hymen  has  been  found  outside  the 
obstructing  membrane.  In  other  words,  the  lower  end  of  the  va- 
gina, which  is  a  solid  structure  in  the  early  stages  of  development 
after  the  fusion  of  Miiller's  ducts  and  before  the  canal  is  formed, 


C  3 

SS. 
S  CD 
>>02 

a -a 


1  ° 

-1  c 


397 


398 


DISEASES  OF  THE  VULVA 


remains  impervious  in  the  adult.  Be  the  cause  what  it  may,  the 
result  is  a  damming  up  of  the  uterine  secretions  with  resulting 
hematocolpos,  hematomctra  and  even  hematosalpinx. 
The  vulva  of  every  female  infant  should  be  inspected  by  the 
obstetrician  and  the  patency  of  the  orifice 
of  the  vagina  determined  by  passing  into 
it  a  catheter.  Most  cases  of  imperf orate 
hymen  are  not  discovered  until  puberty, 
in  rare  instances  the  malformation  has  not 
been  suspected  until  early  marriage.  There 
may  be  few  symptoms,  and  these  nothing 
more  than  a  sense  of  weight  and  fullness  in 
the  pelvis.  As  the  accumulated  blood  in- 
creases in  amount  the  patient  may  experi- 
ence colicky  pains  in  the  abdomen  and  in- 
terference with  micturition  and  defecation. 
Amenorrhea,  when  the  body  shape  and  the 
psychic  changes  of  puberty  announce  the 
presence  of  that  state,  should  lead  to  a 
local  examination,  especially  if  there  is 
a  menstrual  moli- 


F  i  G  .  171 . — Hemato- 
colpos, Caused  by  Atre- 
sia  of  the  Vagina  or 
Imperforate  Hymen. 


men. 

Diagnosis  of  Im- 

perforate  Hymen. — The  diagnosis  rests  on 
the  physical  examination.  Inspection 
shows  a  bulging  in  the  region  of  the  in- 
troitus  vagina?  which  is  of  a  bluish  tinge. 
The  urethral  orifice  is  dilated.  Recto- 
abdominal  palpation  reveals  the  presence 
of  a  fluctuating  mass  in  the  region  of  the 
vagina;  if  the  case  is  an  early  one,  the 
vagina  alone  may  be  dilated,  if  a  later 
case  the  uterus,  or  the  uterus  and  the 
tubes  are  enlarged  (see  Figs.  171,  172  and 
173.)  The  utmost  gentleness  should  be 
employed  and  it  is  wise  not  to  make  too 
exact  a  diagnosis  because  of  the  danger  of 
rupturing  the  tubes,  should  they  be  distended.  A  more  precise 
finding  is  gained  after  an  anesthetic  has  been  administered,  and 


FIG.     172. — Hematocolpos 
and    Hematornetra. 


CONGENITAL  ANOMALIES 


399 


this      ould  not  be  given  until  the   preparations  have  been  made 
for  evacuating  the  fluid. 

Hermaphroditism. — Hermaphroditism  (Hermes  and  Aphrodite), 
the  union  of  the  two  sexes  hi  one  individual,  is  a  term  generally 
used  to  describe  a  person  whose  external  genital  organs  partake  of 
the  characteristics  of  both  sexes.  Every  embryo  is  in  the  begin- 
ning potentially  both  male  and 
female;  some  preponderating  in- 
fluence determining  the  develop- 
ment of  the  Wolffian  or  the  Miil- 
lerian  ducts,  so  that  it  is  not 
strange  that  remnants  of  the  un- 
developed ducts  should  be  found 
in  the  adult.  The  steps  of  the 
development  of  the  sexual  organs 
are  indicated  in  Fig.  71,  page  198 
and  in  Figs.  158-162. 

True  Hermaphroditism. — A  true 
hermaphrodite,  according  to 
Neugebauer,  is  an  individual  who 
can  impregnate  another  and  also 
can  be  impregnated  itself  by 
another  individual;  not  only  that, 
it  may  impregnate  itself.  Accord- 
ing to  this  definition  true  hermaphroditism  occurs  in  the  lower 
animals,  as  in  the  cestopods.  The  gastropods,  on  the  other  hand, 
can  fructify  each  other  but  not  themselves.  True  hermaphroditism 
in  the  functional  sense  does  not  occur  in  man,  but  in  the  sense  that 
an  individual  may  have  a  genital  gland  which  contains  both 
ovarian  and  testicular  tissue,  an  ovotestis,  five  undoubted  cases 
have  been  reported,  by  V.  Salen,  Garre,  Pick,  and  Schickele.  One 
of  Pick's  two  cases  was  that  of  a  woman  who  had  borne  several 
children  and  Carre's  case  was  that  of  a  male  hermaphrodite  twenty 
years  old.  Therefore,  true  hermaphroditism,  defined  as  the  occur- 
rence of  a  combination  gland  of  both  ovary  and  testicle  in  the  same 
person,  does  occur.  A  preponderating  number  of  the  reported 
cases  are  instance's  of  pseudohermaphroditism.  Neugebauer  in  his 
exhaustive  work  has  gathered  together  1,886  cases  of  pseudoher- 
maphroditism in  addition  to  the  five  cases  of  true  hermaphroditism. 


FIG.  173. — Hematocolpos,  Hemato- 
metra  and  Hematosalpinx. 


400  DISEASES  OF  THE  VULVA 

Pseudohermaphroditism . — Pseudohermaphroditism  is  more  often 
of  the  male  variety. 

Male  False  Hermaphroditism. — Here  the  body  form,  stature, 
hair,  and  breasts  are  of  the  male  type;  testicles  are  always  present, 
but  the  external  genital  organs  are  malformed.  The  penis  is  un- 
dersized and  the  glans  imperforate,  while  the  penile  urethra  is 
represented  by  a  groove  running  into  a  cul-de-sac  which  corre- 
sponds to  an  incomplete  vulva.  The  two  halves  of  the  scrotum 
have  failed  to  unite  in  the  median  line,  thus  resembling  the  labia 
majora,  and  enclose  a  rudimentary  vulvar  orifice  scarcely  admit- 
ting a  finger  tip.  One  half  of  the  scrotum  may  contain  a  testis,  and 
the  other  testicle  may  be  in  the  inguinal  canal.  It  is  a  condition  of 
hypospadias  in  the  male.  There  are  many  varieties  of  this  type. 
The  cases  are  apt  to  be  regarded  as  females  and  are  brought  up  as 
girls  until  after  puberty  when  they  show  sexual  inclination  toward 
females. 

Female  False  Hermaphroditism. — This  is  less  common  than  the 
male  kind.  The  ovaries  are  always  present,  but  may  be  in  the 
labia  majora.  The  body  form,  stature,  and  hair  are  of  the  female 
type,  but  the  individual  may  have  a  beard  and  the  breasts  may  be 
poorly  developed.  The  clitoris  is  large,  resembling  a  penis,  the 
labia  majora  are  fused  in  the  median  line  so  that  they  are  like  a 
scrotum,  and  the  vagina  is  small. 

For  a  complete  exposition  of  this  subject,  with  descriptions  and 
illustrations  of  the  many  cases  of  hermaphroditism  that  have  been 
reported,  the  reader  is  referred  to  Neugebauer's  work  ("Her- 
maphroditismus  beim  Menschen,"  1908). 

INJURIES  OF  THE  VULVA 

Injuries  of  the  vulva  may  be  divided  into  (a)  those  due  to  child- 
bearing,  (6)  those  due  to  direct  violence,  and  (c)  those  due  to 
coitus. 

(a)  Childbearing. — The  labia  majora  are  apt  to  be  bruised  and 
lacerated,  more  often  the  former,  by  the  obstetric  forceps.  Lacera- 
tions are  generally  superficial,  but  may  involve  the  vulvo-vagimil 
glands.  Hematoma  of  the  labium  majus  occurs  occasionally  follow- 
ing difficult  labor  and  may  attain  great  size.  It  is  especially  liable 
to  occur  in  patients  who  have  suffered  with  varix  of  the  vulva 


','  G| 

INJURIES  OF  THE  VULVA  r  r  .  AOl 

'- ALLEGE  GF  *fSTfi 

during  late  pregnancy.  Hematoma  is  diagnosed  BjHa'ten&ofgw^tling  r\j\ 
of  a  dark  color,  due  to  the  clotted  blood  showing  through  the  skin 
of  the  labium,  and  it  is  very  sensitive  on  pressure.  Such  a  hema- 
toma  very  seriously  complicates  labor.  The  nymphse  are  torn  now 
and  then,  but  such  wounds  are  seldom  serious.  The  vestibule  may 
be  torn  near  the  clitoris  so  that  dangerous  'hemorrhage  may  result, 
but  this  is  an  unusual  occurrence.  Injuries  of  the  hymen  have 
been  referred  to  under  the  malformations  of  the  hymen,  page 
396,  and  lacerations  of  the  perineum  are  treated  in  the  chapter  on 
diseases  of  the  vagina,  page  372. 

(6)  Direct  Violence. — The  vulva,  because  of  its  situation,  is  pro- 
tected from  the  more  common  forms  of  injury,  but  may  be  injured 
by  falls  astride  of  a  sharp  object,  or  by  kicks,  or  blows.  The  close 
proximity  of  the  unyielding  bony  arch  of  the  pubes  and  the  abun- 
dant blood  supply  of  the  parts  make  wounds  in  this  region  more 
serious.  Women  have  fallen  astride  of  a  chair,  or  a  pitchfork,  or 
the  saddle  of  a  bicycle,  or  a  fence  picket,  with  resulting  wound  of 
the  vulva,  generally  attended  by  excessive  bleeding.  Blows  or 
kicks  are  apt  to  take  effect  on  the  labia  majora  with  resulting 
Jiematoma,  generally  of  one  labium,  and  sometimes  of  considerable 
size.  The  hematoma  may  suppurate,  become  gangrenous,  or,  if  not 
of  a  severe  grade,  may  be  absorbed.  The  dark  blood  generally 
shows  through  the  skin;  the  hematoma  is  not  often  larger  than  a 
closed  fist,  and  of  course  is  very  sensitive.  Children  have  been 
injured  by  splinters  of  wood  penetrating  the  vulva  while  sliding 
down  a  board,  or  by  being  thrown  on  sharp  objects  while 
coasting. 

(c)  Coitus. — Injury  of  the  hymen  at  the  first  intercourse  often 
results  in  bleeding  which  has  been  known  to  be  alarming  in  amount 
in  very  rare  cases;  usually  the  bleeding  is  of  no  moment.  Severe 
injury  of  the  vulva  from  rape  upon  young  girls  has  been  reported, 
the  wound  involving  the  perineum,  labia,  or  even  the  recto- vaginal 
septum,  there  being  cases  on  record  where  a  recto-vaginal  fistula 
resulted  from  brutal  coitus.  Disproportion  in  the  size  of  the  penis 
and  the  vagina  in  the  case  of  young  girls  and  old  women  has  given 
rise  to  injuries,  which  must  be  considered  as  of  infrequent  occur- 
rence. 


402  DISEASES  OF  THE  VULVA 


INFLAMMATION  OF  THE  VULVA :  VULVITIS 

The  vulva,  being  covered  by  modified  skin  and  hair,  is  affected 
by  the  same  sort  of  skin  diseases  as  the  other  hairy  parts  of 
the  body.  The  forms  of  skin  diseases  that  most  frequently  affect 
the  vulva  are,  erythema,  eczema,  herpes,  acne,  tuberculosis,  con- 
dylomata,  kraurosis,  elephantiasis,  thrush,  pediculus  pubis,  syph- 
ilis, erysipelas,  diphtheria,  and  gonorrhea.  The  last  is  the  most 
frequent  of  the  causes  of  inflammation  of  the  vulva;  other  causes 
arc,  lack  of  cleanliness,  irritating  vaginal  discharges,  or  irritating 
urine,  as  in  diabetes  mellitus,  local  irritation,  as  from  scratching 
or  an  ill-fitting  napkin,  and,  finally,  any  constitutional  exhausting 
diseases  that  lessen  the  resisting  power  of  the  tissues. 

Simple  or  Catarrhal  Vulvitis. — Simple  or  catarrhal  vulvitis  is  the 
most  common  form  of  vulvitis  and  may  be  due  to  want  of  cleanliness, 
pediculi  pubis,  excessive  coitus,  abnormal  discharges  from  the  uterus, 
fecal  or  urinary  fistula,  or  malignant  disease.  In  the  acute  form 
it  is  characterized  by  tenderness,  burning  and  throbbing  at  the 
vulva,  smarting  on  urination,  and  profuse,  non-purulent  discharge. 
In  the  chronic  form  itching  and  burning  are  noticeable  symptoms, 
also  a  discharge  that  is  thinner  and  less  in  quantity  than  in  the 
acute  stage  of  the  disease.  The  vulva  is  congested  and  more  or 
less  swollen  in  its  various  parts  and  there  may  be  excoriations  or 
even  ulcerations.  In  some  cases  the  hair  and  sweat  follicles  are 
infected  and  the  vulva  is  studded  with  papules  and  pustules.  This 
follicular  vulvitis  is  a  rare  form  of  vulvar  inflammation  seen  mostly 
in  the  clinics  of  Europe.  In  diphtheritic  vulvitis  a  characteristic 
gray  membrane,  composed  of  fibrin,  is  formed  on  the  vulva,  and  a 
similar  appearing  membrane,  but  with  little  fibrin,  also  occurs  in 
puerperal  cases  from  the  action  of  bacteria  other  than  the  Klebs- 
Loefller  bacillus,  generally  the  streptococcus.  The  superficial 
inguinal  glands  take  up  infective  matter  from  the  vulva  and  even 
in  the  simple,  catarrhal  vulvitis  may  be  enlarged.  The  disease  has 
no  tendency  to  invade  the  vagina  or  urethra  and  microscopic  ex- 
amination shows  the  absence  of  the  gonococcus. 

Gonorrheal  Vulvitis.— In  this  variety,  by  all  odds  the  most  fre- 
quent form  of  vulvar  inflammation,  the  disease  has  a  tendency  to 
invade  the  neighboring  organs,  and  we  have  vaginitis,  endocervi- 


INFLAMMATION  OF  THE  VULVA  403 

citis,  urethritis,  and  inflammation  of  Skene's  and  Bartholin's  glands, 
as  well  as  the  vulvitis  proper;  the  vulvitis,  in  fact,  being  the  least 
important  of  the  gonorrheal  processes.  The  discharge  is  purulent 
and  of  a  yellow  or  greenish-yellow  color;  the  disease  affecting  the 
urethra  early,  there  is  burning,  and  frequent  micturition  from  the 
beginning.  The  inguinal  glands  may  be  involved  and  a  "bubo" 
is  developed  in  the  course  of  a  few  days;  also,  the  vulvo-vaginal 
glands  are  apt  to  be  infected.  The  diagnosis  rests  on  the  severity 
of  the  inflammation  following  a  suspicious  intercourse,  on  the 
presence  of  urinary  symptoms,  on  being  able  to  express  a  drop  of 
pus  from  the  urethra  or  one  of  Bartholin's  glands,  and  on  finding 
the  gonococcus  in  the  discharge.  Gonorrheal  vulvitis  is  not  un- 
common among  infants  and  little  girls,  especially  in  institutions, 
and  may  lead  to  adhesions  of  the  labia  minora  or  even  the  labia 
majora.  The  entire  vulvar  cleft  may  be  closed  except  a  small  open- 
ing either  in  front  or  behind  through  which  the  urine  escapes. 
Lesser  degrees  of  adhesions  are  by  no  means  rare,  and  careful  ex- 
aminations of  the  women  who  present  themselves  in  the  out-patient 
clinics  will  reveal  many  cases  of  agglutination  of  portions  of  the 
nymphse,  or  adhesions  burying  the  glans  clitoridis. 

Diabetic  Vulvitis. — Diabetic  vulvitis  is  an  inflammation  of  the 
vulva  caused  by  the  decomposition  of  the  urine  in  diabetes  mellitus 
by  the  saccharomyces  fungus.  Its  symptoms  are  burning  and 
intense  itching,  and  tenderness  of  the  vulva.  On  inspection  the 
vulva  is  of  a  dull,  reddish  color  and  the  surfaces  of  the  labia  and 
vestibule  are  parchment-like,  corrugated,  and  dry.  Excoriations 
from  scratching  are  to  be  expected,  or  even  the  presence  of  small 
boils,  and  in  time  the  disease  affects  the  skin  of  the  mons  veneris 
and  the  insides  of  the  thighs  and  the  anal  region.  The  diagnosis  is 
made  by  finding  sugar  in  the  urine  and  by  the  appearance  of  the 
vulva,  which  is  most  characteristic. 

Thrush  of  the  Vulva. — This  rare  disease  is  caused  by  the  Sacchar- 
omyces albicans,  just  as  in  the  case  of  parasitic  stomatitis.  It  is 
found  most  often  in  nursing  women,  in  advanced  diabetes,  tuber- 
culosis, cancer  and  in  women  who  are  exhausted  physically.  The 
pails  affected  are  covered  with  slightly  elevated,  snow-white  spots, 
which  have  a  tendency  to  coalesce  and  leave  shallow  ulcers.  The 
saccharomyces  fungus  in  the  form  of  mycelium  and  spores  may  be 
found  in  the  discharges  scraped  from  the  surface. 


401  DISEASES  OF  THE  VULVA 

Elephantiasis  of  the  Vulva. — Elephantiasis  is  extremely  rare  ex- 
cept in  tropical  climates.  It  affects  mostly  the  labia  majora,  but 
may  involve  the  clitoris  or  the  nympluc.  It  occurs  between  the 
twenty-fifth  and  fiftieth  years  of  life,  and  is  characterized  by 
thickening  and  enlargement  of  the  tissues,  sometimes  forming  a 
large  tumor  that  has  fissures  and  ulccrations  on  its  surface. 

Pruritus  Vulvae. — This  is  a  symptom  which  may  be  due  to  a 
variety  of  causes,  and  consists  of  intense  itching  of  the  vulva.  (See 
also  Chapter  X.,  page  160.)  The  various  skin  diseases  such  as  eczema 
and  pediculosis  are  characterized  by  itching,  also  the  vulvitis  due 
to  diabetes,  and  the  presence  of  Ascaris  lumbricoidcs  and  Oxyuris 
vermicularis,  especially  in  young  subjects.  Lack  of  cleanliness 
may  cause  itching  and  so  may  irritating  discharges,  as  well  as  con- 
gestion of  the  vulva,  as  in  varicose  veins  of  the  vulva  and  in  preg- 
nancy. Aside  from  these  definite  causes  the  terminal  nerve  fila- 
ments in  the  vulva  may  be  affected  so  that  itching  results,  as  in 
the  case  of  some  old  women  and  in  certain  nervous  diseases,  and 
we  arc  ignorant  of  the  causation.  For  the  purposes  of  prognosis 
and  treatment  it  is  important  to  determine,  as  far  as  possible,  a 
definite  cause.  Great  sensitiveness  of  the  vulva  may  be  due  to  a 
neuritis  affecting  the  nerves  of  this  region,  and  the  physician  will 
do  well  to  rule  out  this  affection  before  resorting  to  local  treat- 
ment. 

Kraurosis  Vulvae. — Kraurosis  vulva)  is  a  progressive  atrophy 
and  contraction  of  the  tissues  of  the  vulva  of  unknown  cause, 
occurring  mostly  after  the  age  of  forty.  The  disease  affects  the 
nymplur,  clitoris,  and  vestibule  and  begins  as  small  brown  spots, 
of  irregular  shape  and  slightly  depressed,  on  the  surface  of  the  labia 
minora  and  the  vestibule.  Soon  the  tissues  of  the  vulva  become 
tense,  shining,  white,  and  contracted;  the  meatus  urinarius  pre- 
sents a  reddened  prominent  appearance,  and  along  the  caruncuhe 
myrtiformes  are  small  patches  of  subcutaneous  hemorrhage.  The 
nymplue  atrophy.  The  orifice  of  the  vagina  becomes  contracted 
so  that  it  will  barely  admit  the  tip  of  a  finger  without  causing 
hemorrhage  or  great  pain.  The  pubic  hair  has  a  peculiar  stubbly 
appearance  and  may  be  broken  or  may  come  out.  The  labia  majora 
are  not  much  affected  by  the  atrophic  process,  as  a  rule.  Micro- 
scopic examination  of  the  tissues  shows  small-round-celled  infil- 
tration and  great  development  of  fibrous  tissue,  with  absence  of 


INFLAMMATION   OF  THE   VULVA  405 

hair  follicles  and  sebaceous  glands.  Left  to  itself  the  disease  runs 
a  chronic  course  of  five  or  six  years.  The  symptoms  are  great 
irritation,  smarting  on  urination,  and  painful  intercourse,  which 
may  cause  lacerations,  the  parts  being  very  friable;  the  lacerations 
being  severe  if  pregnancy  and  labor  occur.  The  symptoms  may  be 
entirely  relieved  when  the  atrophic  process  has  reached  its 
climax.  The  diagnosis  is  established  by  the  appearance  of  the 
vulva. 

Edema  and  Gangrene  of  the  Vulva. — Edema  of  the  vulva  may 
occur  as  a  result  of  vulvitis,  but  is  more  commonly  the  result  of 
interference  with  the  pelvic  circulation  by  pressure  on  the  pelvic 
veins  by  tumors,  pelvic  inflammatory  masses,  or  the  pregnant 
uterus,  or  it  may  form  a  part  of  a  general  anasarca.  The  nymphse 
and  the  prepuce  of  the  clitoris  are  the  parts  mostly  affected,  but  in 
extreme  cases  the  labia  majora  and  even  the  mons  veneris  become 
enormously  distended.  Pitting  of  the  tissues  on  pressure  is  the 
diagnostic  sign  to  be  looked  for.  Gangrene  may  follow  excessive 
edema  or  erysipelas  of  the  vulva,  or  as  a  complication  of  the  exan- 
themata, also  in  dirty,  underfed  children,  where  it  is  analogous  to 
noma,  or  as  an  epidemic  puerperal  disease,  or  an  acute  inflammation 
independent  of  contagion.  The  nymphae  are  the  portions  of  the 
vulva  most  affected  by  gangrene.  It  begins  usually  as  a  livid  red, 
indurated  swelling  of  one  labium,  soon  breaking  down  into  dirty 
gray  or  dull  red  ulcerations  and  followed  by  a  greenish-black  layer 
of  gangrene. 

Varix  or  Varicose  Veins  of  the  Vulva. — Varix  is  found  often  during 
the  later  months  of  pregnancy.  The  enlarged  veins  are  in  the 
labia  majora,  and  one  or  both  sides  may  be  involved,  the  left 
more  often  than  the  right.  The  vulva  being  well  supplied  with 
blood-vessels  and  also  with  erectile  tissue,  it  is  not  surprising  that 
obstruction  to  the  veins  should  result  in  varix.  The  dark  veins  may 
be  seen  through  the  skin  of  the  labium,  and  to  the  touch  present 
the  characteristic  feeling  of  a  bag  of  worms,  as  in  the  case  of  vari- 
cocele  of  the  scrotum.  Similar  varicosities  are  to  be  found  in  the 
veins  of  the  upper  and  inner  thigh,  and  also  in  the  vagina. 

Rupture  of  the  veins  of  the  vulva  during  delivery  results  in  a 
hematoma  of  the  vulva. 


406  DISEASES  OF  THE  VULVA 


VENEREAL  LESIONS  OF  THE  VULVA 

Venereal  lesions  include  chancroids,  chancre,  mucous  patches, 
and  condylomata  lata  and  acuminata. 

Chancroids  are  most  often  found  on  the  fourchctte,  the  inner 
surfaces  of  the  labia  rnajora,  the  nympha),  and  the  vestibule;  they 
are  multiple  as  a  rule,  and  are  more  common  among  the  uncleanly. 
Secondary  infection  is  usual  and  fresh  chancroids  keep  appearing; 
and  often  some  that  seem  to  be  healed  break  down  and  ulcerate 
anew.  The  lesion  begins  as  a  pustule  that  soon  becomes  an  ulcera- 
tion;  the  ulceration  has  a  punched-out  undermined  edge,  a 
soft,  non-indurated  base,  which  has  a  granular,  uneven  surface 
covered  by  a  purulent  discharge.  This  discharge  is  auto-inoculable. 
The  sore  is  sensitive  to  touch.  The  chancroid  appears  about  forty- 
eight  hours  after  an  infecting  coitus  and  develops  rapidly.  Second- 
ary infection  of  the  lymphatic  glands  of  the  groin  (a  bubo) 
involves  commonly  only  one  gland  in  a  severe  grade  of  inflamma- 
tion, causing  pain  and  often  suppuration. 

Chancre  of  the  Vulva. — This  is  relatively  rare,  an  extra-genital 
situation  of  the  initial  lesion  of  syphilis  being  more  frequent  in  the 
female  than  in  the  male.  Also,  because  of  the  inaccessibility  of 
the  parts  and  the  trifling  discomfort  to  which  they  commonly 
give  rise,  chancres  of  the  vulva  often  escape  observation.  The 
initial  lesion  of  syphilis,  if  situated  on  the  vulva,  is  generally  to  be 
found  on  the  labium  majus;  the  next  most  frequent  situation  is  the 
fourchette,  then  the  nymphse,  the  clitoris,  and  the  mons  veneris  in 
order  of  frequency.  The  chancre  appears  as  a  hard,  red  lump  which 
soon  ulcerates;  the  induration  of  its  base  being  a  characteristic 
feature,  also  the  enlargement,  in  six  to  ten  days  after  its  appearance, 
of  the  individual  lymphatic  glands  in  most  intimate  connection  with 
it.  The  chancre  appears  after  an  average  period  of  twenty-six  days 
from  the  time  of  inoculation,  and  is  nearly  always  single,  but  may 
be  multiple  if  several  abrasions  have  been  inoculated  at  the  same 
time.  The  ulcer  formed  by  the  chancre  has  smooth  edges,  often 
elevated  or  sloping,  never  undermined,  and  the  base  is  of  smooth 
surface  and  indurated,  and  the  secretion,  which  is  serous  and 
scanty,  is  not  auto-inoculable.  The  infection  of  the  lymphatic 


VENEREAL  LESIONS  OF  THE  VULVA  407 

glands  of  the  groins,  primary  adenopathy,  affects  several  glands  in 
a  painless  enlargement. 

Diagnosis  of  Chancre  of  the  Vulva. — The  diagnosis  of  chancre  is 
often  a  matter  of  extreme  difficulty.  The  discovery  of  the  Spiro- 
chseta  pallida  in  the  secretions  or  a  smear  from  the  chancre  makes 
the  diagnosis  sure,  but  failing  this  the  three  most  important  points 
are,  the  long  period  of  incubation  of  the  disease,  the  induration  of 
the  base  of  the  sore,  and  the  enlargement  of  the  individual  lym- 
phatic glands  in  the  groin. 

A  recent  writer  on  the  diagnostic  significance  of  the  spirochseta 
pallida,  R.  P.  Campbell,  Jour.  American  Medical  Association,  Vol. 
LIV,  March  19,  1910,  page  924),  speaks  as  follows  from  a  large 
clinical  experience  in  Montreal:  "It  should  be  possible  to  find  the 
spirochseta  pallida  in  approximately  100  per  cent  of  chancres  ex- 
cluding those  which  are  nearly  healed,  or  have  been  actively  treated, 
and  some  cases  of  mixed  infection.  In  view  of  this  fact,  treatment 
should  not  be  begun  before  the  diagnosis  is  confirmed  by  finding 
the  spirochsete." 

Differential  Diagnosis. — Herpes  of  the  vulva  is  excluded  by  the 
appearance  and  the  feel  of  the  herpes:  a  superficial  group  of 
vesicles  with  a  soft  base  disappearing  after  a  short  time.  The 
crops  of  herpes  may  be  multiple,  while  chancre  is  single. 

Furunculosis  of  the  vulva  has  been  mistaken  for  chancre.  Here 
the  boils  are  apt  to  be  multiple  and  run  the  usual  course  of  a 
furuncle.  The  chief  lesion  that  is  confounded  with  chancre  is  the 
chancroid,  and  the  distinguishing  characteristics  of  the  two  lesions 
have  been  touched  upon  in  the  two  preceding  pages. 

Mucous  Patches. — Mucous  patches  in  the  vulva  are  a  frequent 
manifestation  of  secondary  syphilis.  They  occur  as  moist  papular 
syphilides  and  erosions,  and  have  a  discharge  with  a  foul  odor. 
The  Spirochiuta  pallida  is  abundant  in  scrapings  from  these  patches 
and  they  are  a  most  frequent  source  of  syphilitic  contagion.  They 
are  apt  to  be  converted  into  condylomata  lata  or  into  a  fusion  of 
several  papules  to  form  cauliflower-like  growths  on  the  genitals,  with 
fissures  and  ulcerations.  Condylomata  accuminatq,  occurring  in 
cases  of  gonorrhea  and  unclean  persons  with  irritating  vaginal 
discharge,  are  not  the  same  as  the  condylomata  lata.  The  acum- 
inate variety  are  pointed,  more  wail-like,  pedunculated,  and  of  a 
branched,  tree-like  character.  Their  color  may  be  that  of  the  sur- 


408  DISEASES  OF  THE  VULVA 

rounding  skin,  or,  if  the  epithelium  has  been  removed  by  friction  or 
maceration,  they  are  of  a  deep  red  hue.  They  have  a  foul  discharge 
and  may  affect  any  portion  of  the  vulva  or  the  inner  surfaces  of  the 
thighs,  and  may  grow  to  the  size  of  a  fist. 

Gumma. — A  gumma  as  a  manifestation  of  tertiary  syphilis  may 
develop  as  a  round  tumor  in  the  labium  majus.  It  has  a  tendency 
to  break  down  by  a  sort  of  fatty  degeneration,  but  not  to  suppurate. 


TUBERCULOSIS  OF  THE  VULVA 

This  is  a  rare  affection,  there  being  on  record  only  some  fifteen  or 
twenty  cases.  The  disease  is  generally  seen  in  the  ulcerative 
stage  in  women  between  twenty  and  forty  years  of  age,  the  ulcers 
being  of  a  grayish  color,  of  varying  size,  with  irregular  edges,  ex- 
hibiting in  their  bases  tubercles  in  process  of  cheesy  degeneration, 
and  friable,  poorly  nourished  granulations.  The  ulcers  are  situ- 
ated in  the  vestibule  or  on  the  labia  or  perineum.  The  diagnosis 
is  often  difficult,  numerous  sections  of  the  ulcerated  tissues  being 
made  before  tubercles  and  the  tubercle  bacilli  are  found.  The 
i  nguinal  glands  are  not  affected  in  this  disease ;  the  ulceration  pro- 
ceeds slowly,  having  a  course  of  from  eight  to  ten  years,  and  there 
is  no  marked  induration  of  the  tissues.  The  disease  has  been  called 
also  lupus  vulva?,  and  esthiomene  de  la  vulve. 


CYSTS  OF  BARTHOLIN'S  GLAND 

It  is  not  surprising  that  the  duct  of  the  vulvo-vaginal  gland, 
which  is  only  half  a  millimeter  in  diameter  at  its  exit,  should  become 
occluded  as  a  result  of  infective  inflammation,  thus  damming  up 
the  secretions.  Gonorrheal  inflammation  is  supposed  to  be  a 
cause  for  the  obliteration  of  the  duct  of  the  canal  and  therefore  a 
cause  of  the  formation  of  a  cyst.  Be  that  as  it  may,  cysts  of  Bar- 
tholin's  gland  are  of  sufficiently  common  occurrence.  They  are 
usually  unilateral,  vary  in  size  from  half  a  centimeter  to  four 
centimeters  in  diameter,  and  occur  during  the  childbearing  period 
of  life.  The  smaller  ones  may  be  due  to  the  occlusion  of  a  second- 
arv,  branching  duct,  rather  than  the  main  duct. 


ABSCESS  OF  BARTHOLIN'S  GLAND 


409 


A  cyst  gives  little  trouble  as  a  rule,  though  the  larger  ones  may 
interfere  with  coitus;  they  are  rarely  painful.  The  patient  gen- 
erally gives  a  history  of  old  inflammation  of  the  vulva.  The 
diagnosis  consists  in  detecting  a  fluctuating,  not  tender  swelling  in 
the  situation  of  the  vulvo- vaginal  gland  (see  figures  from  Huguier). 

Cysts  of  the  secondary  ducts  and  of  the  gland  itself  are  situated 


FIG.  174.— Cyst  of  the  Left  Bartholin's  Gland.     (After  Huguier.) 

deeper  in  the  tissues  and  farther  from  the  introitus  vagina3  than 
cysts  of  the  main  duct,  and  such  cysts  may  be  multilocular,  where- 
as cysts  of  the  main  duct  are  always  unilocular.  When  laid  open 
cysts  of  Bartholin's  gland  are  found  to  be  filled  with  a  glairy, 
colorless,  whitc-of-egg  mucus,  and  to  be  lined  by  a  smooth  mem- 
brane. 

ABSCESS  OF  BARTHOLIN'S  GLAND 

Abscess  of  the  vulvo-vaginal  glands  is  very  common  and  is  due, 
in  a  large  proportion  of  cases,  to  gonorrhea.  One  gland  at  a  time 
is  affected,  as  a  rule,  more  often  the  left,  and  the  disease  is  generally 


410 


DISEASES  OF  THE  VULVA 


met  with  in  women  under  thirty  years  of  age,  who  are  likely  to 
have  gonorrhea,  such  as  prostitutes  and  women  of  loose  habits. 
The  duct  of  the  gland,  or  the  gland  itself,  may  be  involved,  Huguier 
having  reported  cases  of  the  former.  (See  Fig.  175.) 

In  severe  and  neglected  cases  the  gland  becomes  disorganized. 
Huguier  thought  that  cysts  of  the  duct  or  gland  become  infected 
and  suppurate. 

Suppuration  in  the  gland  or  canal  is  apt  not  to  come  on  until  the 


Obliterated 
ttcreTory  canaU 


of  the 


Fig.  175.— Abscess  of  the  Ducts  of  Both  Bartholin's  Glands.     (After  Huguier..) 

later  stages  of  gonococcus  infection.  Then  there  is  a  recurrence  of 
heat  and  burning  in  the  vulva  with  sharp  pains,  slight  elevation  of 
temperature,  and  tenderness  of  the  tissues,  the  symptoms  being 
aggravated  by  standing,  walking,  and  sitting  even,  the  patient 
being  most  comfortable  in  the  recumbent  posture.  There  may  be 
retention  of  mine,  or  the  urine  simply  smarts.  Examination 
shows  swelling  and  edema  of  the  labium  and  sometimes  pus  escapes 


ABSCESS  OF  BARTHOLIN'S  GLAND 


411 


from  the  orifice  of  the  duct  on  the  inner  surface,  or  the  abcess  may 
be  evacuated  spontaneously  through  openings  below  the  orifice. 
The  inguinal  lymphatic  glands  are  affected  sometimes  and  a  "  bubo  " 
results.  After  the  subsidence  of  the  acute  inflammation  the  vulvo- 
vaginal  gland  is  apt  to  remain  in  a  state  of  chronic  inflammation 
and  a  drop  of  pus,  perhaps  with  a  greenish  tinge,  or  a  muco-puru- 


FIG.  170. — Abscess  of  Both  Bartholin's  Glands.  (After  Huguier.)  A  Drop 
of  Pus  is  shown  in  the  Orifice  of  Each  Duct.  Note  Relation  of  Orifices  to 
Introitus  Vagina). 

lent  discharge  issues  from  the  duct.  At  this  stage  the  orifice  is 
surrounded  by  a  red  areola  which  resembles  a  flea  bite,  the  so-called 
macula  yonorrhoica  of  Sangcr.  It  is  in  this  stage  that  infection  is 
apt  to  be  transmitted  to  the  male  and  light  up  in  his  urethra  an 
acute  gonorrhea,  or  it  may  cause  puerperal  sepsis  or  ophthalmia 
neonatorum.  Relapse  is  common  in  abscess  of  Bartholin's  gland 


412  DISEASES  OF  THE  VULVA 

and  the  opposite  gland  may  become  infected,  therefore  prompt 
surgical  treatment  is  indicated.  Smears  should  be  made  from  the 
discharges  and  examined  for  the  gonococcus. 


DIFFERENTIAL  DIAGNOSIS  OF  CYSTS  AND  ABSCESS 

In  cases  of  long-standing  inflammation  the  tissues  may  be  so 
thickened  that  malignant  disease  is  simulated.  Microscopic  ex- 
amination of  tissue  excised  will  establish  the  diagnosis.  A  rectal 
fistula  discharging  through  the  labium  has  been  mistaken  for  an 
abscess  of  Bartholin's  gland.  Examination  per  rectum  in  such  a 
case  reveals  brawny  swelling,  and  the  opening  of  the  fistula  in  the 
bowel  may  be  made  out  by  means  of  the  proctoscope  and  the 
probe.  Hematoma  of  the  labium  makes  a  more  uniform  swelling 
than  a  cyst  or  abscess  and  feels  doughy,  also  the  skin  is  dark  in  the 
case  of  the  hematoma  and  there  is  a  history  of  injury  or  of  recent 
parturition.  Inguino-labial  hernia  appears  in  the  upper  part  of 
the  labium  and  tends  to  disappear  when  the  patient  lies  down. 
There  is  an  impulse  on  coughing,  and  in  the  case  of  hydrocele  of 
the  canal  of  Nuck  the  swelling  is  also  in  the  upper  part  of  the 
labium,  but  it  is  irreducible.  Hydrocele  of  the  Canal  of  Nuck  is 
treated  in  the  chapter  on  the  diseases  of  the  uterine  ligaments. 
(See  Chapter  XII.,  page  213.) 

LABIAL  HERNIA 

An  inguinal  hernia  not  infrequently  finds  its  way  into  the  labium 
majus  and  sometimes  there  is  a  double  hernia  of  this  sort.  The 
hernia  descends  through  the  inguina  canal  and  follows  the  course 
of  the  round  ligament  into  the  labium;  this  form  of  hernia  being 
analogous  to  scrotal  hernia  in  the  male.  The  hernial  sac  may  con- 
tain only  omeiitum  or  it  may  hold  intestine,  the  uterine  tubes,  the 
ovaries,  or  even  the  uterus.  It  is  caused  by  the  failure  of  the  canal 
of  Nuck  to  become  obliterated.  The  patient  complains  of  pains  in 
the  region  of  the  hernia,  especially  on  exertion,  and  is  apt  to  suffer 
with  dyspepsia  and  constipation.  If  the  hernia  is  reducible  the 
lump  in  the  vulva  disappears  when  the  patient  is  in  the  recumbent 
posture. 


BENIGN  TUMORS  OF  THE  VULVA  413 

If  the  sac  contains  omentum  the  swelling  is  irregular  in  feel, 
provided  the  fat  over  the  tumor  is  not  excessive  in  amount,  thus 
obscuring  the  tactile  sense.  The  percussion  note  is  flat  and  there 
is  no  gurgling  sound  in  it  when  reduced  and  very  little  impulse  on 
coughing. 

If  the  hernial  sac  contains  intestine  the  swelling  is  smooth,  regu- 
lar, and  elastic.  It  is  increased  in  size  and  becomes  more  tense  on 
coughing  or  straining,  and  if  reducible  disappears  or  becomes 
smaller  when  the  patient  lies  down.  As  the  hernia  goes  back  into 
the  abdominal  cavity  a  gurgling  sound  is  heard.  The  tumor  of  the 
labium  is  tympantic  to  percussion  and  an  impulse  is  transmitted 
to  it  when  the  patient  coughs. 

Should  an  ovary  be  in  the  hernial  sac  pressure  will  cause  pain 
similar  to  the  pain  experienced  when  the  normal  ovary  is  pressed 
between  the  ringers  in  a  bimanual  examination. 

If  the  uterus  is  in  the  sac  bimanual  examination  of  the  pelvis 
will  reveal  the  absence  of  the  uterus  from  its  usual  situation. 

Differential  Diagnosis. — Hernia  into  the  labium  must  be  differ- 
entiated from  hydrocele  of  the  canal  of  Nuck,  from  a  tumor  of  the 
labium,  or  a  cyst  of  Bartholin's  gland.  From  the  first  it  is  distin- 
guished by  the  fact  that  it  is  tympanitic,  has  an  impulse  on  coughing, 
may  have  an  irregular  contour,  is  reducible,  and  has  gurgling  on 
reduction.  Hydrocele  is  irreducible,  is  of  smooth  outline,  has  no 
impulse,  and  is  flat  to  percussion.  A  solid  tumor  of  the  labium  is 
generally  of  hard  consistency;  it  projects  from  the  surface,  has 
no  impulse  on  coughing  and  no  gurgling.  A  cyst  of  Bartholin's 
gland  is  globular,  has  no  impulse,  is  flat  to  percussion,  and  is  situ- 
ated in  the  lower  part  of  the  labium,  whereas  a  hernia  is  oval,  has 
an  impulse,  may  be  tympanitic,  and  is  in  the  upper  part  of  the 
labium. 

BENIGN  TUMORS  OF  THE  VULVA 

These  are  fibroma,  myoma,  myxoma,  neuroma,  angioma,  lipoma, 
and  cysts.  They  are  rare.  Most  of  them  affect  the  labia  majora. 
J.  Bondi  has  found  three  sorts  of  cysts  of  the  labia  minora,  of  which 
the  mucous  cysts  are  the  most  frequent.  He  thinks  they  represent 
remains  of  the  Wolffian  bodies.  They  are  situated  in  the  upper  part 
of  the  labium.  Lipoma  may  grow  from  the  fatty  tissue  of  the 


414  DISEASES  OF  THE  VULVA 

mons  vcncris  or  the  labia  majora,  or  even  from  the  nymphse,  and 
may  attain  considerable  size.  The  diagnosis  of  benign  tumors 
can  not  be  made  exactly,  short  of  removal  and  microscopic  ex- 
amination of  the  tissues  of  the  tumor.  Slow  growth  is  the  rule,  and 
the  only  symptoms  are  interference  with  coitus  and  the  discomfort 
attending  the  presence  of  the  growth. 


MALIGNANT  TUMORS  OF  THE  VULVA 

These  arc  cancer  and  sarcoma. 

Cancer. — Primary  cancer  of  the  vulva  is  rare.  It  is  a  disease  of 
advanced  life,  usually  occurring  between  the  ages  of  forty-five  and 
sixty.  Its  most  frequent  point  of  origin  is  the  groove  between 
the  nympha  and  the  labium  majus,  but  it  may  develop  from  the 
prepuce  of  the  clitoris  or  any  of  the  structures  of  the  vulva.  The 
cancer  appears  in  one  of  three  forms,  as  a  circumscribed  elevation, 
as  a  deep  ulceration  with  infiltrated  margins,  or  as  a  diffuse  infil- 
tration. The  circumscribed  growth  is  a  firm  tumor  rising  from 
the  surface  of  the  vulva  and  more  or  less  movable  on  the  under- 
lying, infiltrated  tissues.  If  the  cancer  has  broken  down  it  is  a 
friable  tabulated  or  warty  mass,  showing  points  of  ulceration.  The 
surface  is  granular,  furrowed,  and  bright  red  in  color,  and  the  base 
is  indurated.  The  carcinoma  may  invade  the  deeper  tissues  from 
the  beginning,  not  forming  a  circumscribed  growth  on  the  surface. 
In  this  case  the  tissues  become  of  a  brawny  hardness  and  are 
thickened  over  an  area  of  considerable  extent.  This  sort  of  growth 
may  progress  very  slowly,  and  ulceration  may  not  appear  for 
several  years.  The  tendency  of  the  disease  is  to  involve  the  struc- 
tures of  one  wide  of  the  vulva  and  then  to  extend  to  the  opposite 
side,  perhaps  by  inoculation.  The  lymphatic  glands  of  the  groin 
are  involved  early,  and  the  individual  glands  are  to  be  distin- 
guished as  separate,  hard  lumps. 

Cancer  of  Bartholin's  gland  occurs  as  a  round,  indurated  tumor, 
often  as  large  as  a  hen's  egg,  in  the  lower  portion  of  the  labium 
majus.  The  tumor  is  generally  very  vascular,  and  large  vessels 
can  be  made  out  in  the  overlying  skin. 

Cancer  of  the  vulva  is  of  the;  type  of  squamous-celled  carcinoma, 
and  cancer  "pearls,"  due  to  horny  degeneration  of  the  centers  of 


MALIGNANT  TUMORS  OF  THE   VULVA  415 

the  epithelial  nests,  are  abundant.  Like  cancer  in  other  situations 
in  the  genital  organs,  this  form  of  cancer  has  no  symptoms  which 
are  peculiar  to  itself.  Pain  is  a  late  symptom  after  the  disease 
has  extended  and  involved  the  larger  nerve  trunks.  Ulceration 
causes  local  tenderness  and  a  discharge. 

Differential  Diagnosis  of  Cancer. — In  the  early  stages  of  cancer 
the  following  diseases  must  be  excluded:  tuberculosis,  condylomata 
lata  and  acuminata,  chancre,  chancroids,  and  urethral  caruncle. 
Tuberculosis  occurs  in  younger  women,  i.e.,  between  twenty  and 
forty  years  of  age,  and  is  of  slower  growth;  the  nodules  are  mul- 
tiple and  soft,  the  induration  of  the  base  being  absent;  tubercles 
may  often  be  seen  in  the  cheesy  degenerated  areas;  and  the  in- 
guinal glands  are  not  involved.  The  microscope  will  settle  a  doubt- 
ful diagnosis.  It  is  to  be  remembered  that  the  two  diseases  are 
both  present  sometimes  in  the  same  case.  The  two  sorts  of  condy- 
lomata are  excluded  by  the  history;  in  the  case  of  condylomata 
lata  there  is  a  history  of  syphilis,  and  in  condylomata  acuminata, 
of  gonorrhea;  also  by  the  absence  of  ulceration  and  pain. 

Chancre  in  its  early  stages  may  resemble  cancer.  In  the  former 
there  is  a  history  of  infection  followed  by  a  definite  period  of  in- 
cubation, twenty-six  days.  The  initial  lesion  is  not  painful,  its 
ulcer  shows  no  tendency  to  spread  to  the  surrounding  tissues,  and 
its  discharge  is  scanty,  muco-purulent,  and  thin,  as  opposed  to  the 
profuse  purulent  discharge  of  the  cancerous  ulcer.  If  the  Spiro- 
chieta  pallida  can  be  found  in  smears  from  the  surface  the  diag- 
nosis of  chancre  is  made  certain.  Also,  the  secondary  symptoms 
of  syphilis  are  developed  within  six  weeks  after  the  appearance  of 
the  initial  lesion. 

Chancroids  are  preceded  by  a  history  of  infection  two  days  or  so 
before  the  development  of  the  ulcers,  which  are  generally  multiple. 
Only  one  lymphatic  gland  at  a  time  is  involved  as  a  rule  in  chan- 
croids, and  the  gland  tends  to  suppurate;  in  cancer  several  glands 
are  affected  and  they  do  not  suppurate.  The  chancroid  ulcers  are 
punched  out,  with  undermined  edges,  and  their  bases  are  of  smooth 
surface,  and  arc  not  indurated.  The  ulcer  from  chancre  is  single, 
it  has  sloping  edges,  and  a  rough  and  indurated  base.  Urethral 
caruncle  occasionally  simulates  beginning  cancer.  Caruncle  is, 
however,  of  soft  consistency.  When  ulcerated  it  should  be  removed 
promptly  and  subjected  to  a  microscopic  examination. 


41G  DISEASES  OF  THE  VULVA 

Sarcoma  of  the  Vulva. — Primary  sarcoma  of  the  vulva  is  ex- 
tremely rare  and  occurs  in  young  subjects  as  a  rule.  The  melanotic 
variety  is  the  one  most  often  found,  but  spindle-celled  and  round- 
celled  forms  have  been  reported.  In  the  melanotic  variety  the 
lesions  are  multiple  and  appear  as  hard,  round  nodules  several 
centimeters  in  diameter,  of  a  black  or  brown  color,  and  originating 
in  warts,  moles,  or  luevi.  The  nodules  tend  to  coalesce  and  to 
become  ulcerated,  but  do  not  attain  great  size.  In  the  other 
varieties  the  nodules  are  generally  single,  grow  rapidly,  and  may 
attain  considerable  proportions,  even  as  large  as  a  man's  head. 
They  do  not  ulcerate  and  the  lymphatic  glands  arc  rarely  affected. 


CHAPTER  XXII 


Diagnosis  of  normal  uterine  pregnancy,  p.  417:  During  the  first  three 
months,  p.  418;  History,  p.  418,  Amenorrhea,  p,  419,  Nausea  and  vomit- 
ing, p.  419,  Salivation  and  minor  digestive  disturbances,  p.  420,  Breasts, 
p.  420,  Leucorrhea,  p.  420,  Bladder  disturbances,  p.  420;  Inspection  and 
palpation,  p.  420,  Breasts,  p.  421,  Areola,  p.  421,  Inspection  of  the  vulva  and 
vagina,  p.  421,  Bimanual  touch,  p.  423.  During  the  last  six  months,  p. 
426;  History,  p.  426,  Quickening,  p.  426;  Inspection  and  palpation,  p.  426, 
Gait,  p.  426,  Figure,  p.  426,  Breasts,  p.  426,  Secondary  areola,  p.  426,  Vulva,  p. 
427,  Bimanual  touch,  p.  427,  Internal  ballottement,  p.  429,  Abdomen,  p.  427; 
Auscultation,  p.  429,  Tabular  statement  of  symptoms  and  signs  of  pregnancy 
by  months,  p.  430.  Differential  diagnosis  of  normal  pregnancy,  p.  431; 
During  the  first  three  months,  p.  431,  Anteflexion,  p.  431,  Chronic  subin- 
volution,  p.  431,  Fibroid  in  the  anterior  wall,  p.  431,  Retroflexion,  p.  431, 
Extra-uterine  pregnancy,  p.  431;  During  the  last  six  months,  p.  432. 

Diagnosis  of  abnormal  uterine  pregnancy,  p.  432:  Diagnosis  of  retro- 
flexion  and  incarceration  of  the  pregnant  uterus,  p.  432.  Diagnosis  of 
interstitial  pregnancy  and  of  pregnancy  in  a  rudimentary  horn  of  a 
bicornute  uterus,  p.  433.  Diagnosis  that  pregnancy  has  occurred  previously, 
p.  433.  Diagnosis  of  multiple  pregnancy,  p.  434.  Diagnosis  of  pernicious 
vomiting  of  pregnancy,  p.  434. 

Diagnosis  of  abortion,  p.  436:  Definitions,  p.  436.  Frequency,  p.  437. 
Etiology,  p.  437.  Symptoms,  p.  438.  Diagnosis,  p.  439;  Diagnosis  of 
threatened  abortion,  p.  439;  Diagnosis  of  inevitable  abortion,  p.  439; 
Diagnosis  of  abortion  partially  or  wholly  completed,  p.  440;  Diagnosis 
of  miscarriage,  p.  440.  Differential  diagnosis,  p.  440. 

Diagnosis  of  hydatidiform  mole,  p,  441 :  Pathology,  p.  441.  Symptoms, 
p.  443.  Diagnosis,  p.  443. 


THE  DIAGNOSIS  OF  NORMAL  UTERINE  PREGNANCY 

THE  diagnosis  of  normal  uterine  pregnancy  offers  often  many 
difficulties  to  the  practising  physician  and  is  perhaps  the  most 
important  depart  ment  of  diagnosis.  Vander  Veer  collected  seventy- 
seven  instances  of  abdominal  operations  on  supposedly  pathological 
growths,  some  of  the  operators  being  men  of  note,  where  the  pa- 
tient was  pregnant  in  each  instance.  Hirst  mentions  the  fact 
27  417 


418  NORMAL   UTERINE   PREGNANCY 

that  a  gynecologist  on  the  staff  of  a  large  hospital  has  twice  oper- 
ated for  fibroid  tumors  of  the  womb,  and  only  after  the  amputation 
of  the  uterus  found  that  it  was  pregnant,  and  not  the  seat  of  a 
fibroid  tumor  at  all.  Both  patients  died.  I  have  seen  the  same 
tiling  happen  in  the  experience  of  a  prominent  surgeon  to  one  of 
the  largest  hospitals,  although  the  subsequent  fate  of  the  patient 
was  unknown.  I  have  also  known  of  a  surgeon  of  large  experience 
operating  for  ovarian  tumor  on  the  wife  of  a  noted  obstetrician, 
the  diagnosis  being  made  by  the  apprehensive  husband  and  by  an 
internist,  the  operation  proving  that  there  was  no  ovarian  tumor, 
the  excessive  abdominal  enlargement  being  due  to  pregnancy  and 
hydramnios.  Mistakes  are  so  frequent  that  no  excuse  is  necessary 
for  occupying  space  in  describing  a  subject  which,  by  a  strict  in- 
terpretation, belongs  in  the  domain  of  obstetrics. 

The  diagnosis  of  pregnancy  depends  on  the  history;  on  inspection 
of  the  face,  neck,  figure,  breasts,  abdomen,  and  vagina;  on  the  bi- 
manual  examination,  and,  in  the  later  months,  on  auscultation  of 
the  abdomen. 

DURING  THE  FIRST  THREE  MONTHS  OF  PREGNANCY 

The  diagnosis  of  pregnancy  before  the  fetal  heart  sounds  are 
heard  or  fetal  movements  felt  in  the  fifth  or  sixth  month  is  not  an 
absolute  certainty;  still,  the  strongest  sort  of  a  probability  may 
be  expressed  if  all  the  facts  are  taken  into  consideration.  The 
demonstration  of  the  changes  in  the  genital  organs  due  to  the  in- 
creased blood  supply  and  the  growth  of  the  ovum  form  the  basis  of 
a  diagnosis;  contributory  facts  are  the  alterations  in  the  breasts, 
the  body  form  and  carriage,  and  the  effects  on  the  nervous  system. 

History 

To  got  the  history  of  pregnancy  is  not  always  an  easy  matter, 
for  patients  not  infrequently  conceal  the  facts  either  because,  in 
the  ca.se  of  the  unmarried,  they  hope  the  physician  may  pass  a 
sound  into  the  uterus  and  cause  abortion,  or  they  are  ashamed  to 
acknowledge  immorality,  or,  in  the  case  of  those  pregnant  for  the 
first  time,  because  of  inaccurate  observation.  Patients  who  have 
been  pregnant  previously  can  say  sometimes  that  pregnancy  began 
with  a  particular  coitus  when  especially  pleasurable  sensations 


FIRST  THREE  MONTHS  OF  PREGNANCY  419 

were  experienced,  also  morbid  cravings  for  special  sorts  of  food  or 
disturbances  of  digestion  have  been  the  same  as  with  former  preg- 
nancies. 

Amenorrhea. — Absence  of  menstruation  is  one  of  the  chief  symp- 
toms of  pregnancy.  In  questioning  the  patient  the  exact  date  of 
the  beginning  of  the  last  menstruation  should  be  obtained  and  also 
how  long  it  lasted,  and  whether  it  was  hi  all  respects  similar  to  the 
usual  menstrual  periods.  Did  coitus  occur  soon  after  this  period? 
The  end  of  the  last  catamenia  is  the  date  from  which  the  beginning 
of  pregnancy  is  usually  reckoned.  If  the  patient  has  been  always 
regular  in  her  menstruation,  amenorrhea  of  two  months  is  a  most 
suspicious  circumstance;  if,  on  the  other  hand,  she  has  been 
habitually  irregular  or  if  she  is  nursing  a  baby,  so  much  importance 
can  not  be  attached  to  it.  Cases  are  on  record  where  menstruation 
has  occurred  at  irregular  intervals  during  the  entire  pregnancy; 
in  fact,  one  or  two  shows  of  blood  during  the  first  few  months  are 
by  no  means  uncommon.  About  half  of  all  nursing  women  men- 
struate during  lactation,  and  as  the  number  of  pregnancies  in- 
crease the  tendency  to  menstruate  while  nursing  increases  also, 
therefore  amenorrhea  during  lactation  is  not  a  constant  sign. 
Baudelocque,  Deventer,  and  others  have  reported  instances  of 
regular  menstruation  occurring  only  during  gestation,  but  such 
cases  are  rare.  Amenorrhea  may  occur  hi  chlorosis,  maldevelop- 
ment  of  the  uterus,  or  the  beginning  of  the  menopause,  in  tuber- 
culosis, obesity,  acute  constitutional  diseases,  prolonged  lactation, 
chronic  poisonings,  particularly  lead,  or  from  change  of  climate, 
or  profound  mental  disturbance.  Amenorrhea  is  common  in  girls 
who  have  immigrated  from  a  foreign  country.  A  majority  of  the 
Irish  girls  seen  in  the  out-patient  clinics  of  Boston  have  amen- 
orrhea for  several  months  after  arriving  in  this  country.  Acro- 
megaly,  occurring  as  it  generally  does  in  young  subjects,  is  apt  to 
have  complete  amenorrhea  as  one  of  its  first  symptoms,  and  tu- 
mors of  the  base  of  the  brain,  especially  those  involving  the  hy- 
pophysis cerebri,  as  pointed  out  by  Harvey  Gushing,  have  amen- 
orrhea as  a  prominent  symptom. 

Nausea  and  Vomiting. — The  morning  sickness  of  pregnancy  is  a 
fairly  common  but  by  no  means  an  invariable  accompaniment  of 
gestation.  It  varies  from  an  occasional  qualm  to  active  nausea 
and  vomiting  occurring  when  first  assuming  the  erect  posture  in 


420  NORMAL   UTERINE   PREGNANCY 

the  morning.  Some  patients  can  «not  brush  their  teeth  without 
being  nauseated.  The  symptom  does  not  manifest  itself  as  a  rule 
until  the  fourth  or  fifth  week,  but  may  begin  as  soon  as  ten  days 
after  conception.  It  occurs  also  in  Bright's  disease,  gastritis,  and 
chlorosis.  These  diseases  must  be  ruled  out,  and  if  there  has  been 
a  previous  pregnancy,  nausea  and  vomiting  will  probably  have 
occurred  with  it.  The  symptom  must  be  regarded  as  due  to  the 
enlargement  and  stretching  of  the  uterine  muscle  fibers  and  nerves. 
The  nausea  may  occur  at  other  times  than  in  the  morning  and  may 
persist  throughout  pregnancy,  although  it  generally  ceases  after 
the  third  month. 

Salivation  and  Minor  Digestive  Disturbances. — An  excessive  flow 
of  saliva,  heartburn,  eructations,  and  abnormalities  in  appetite 
such  as  longings  for  strange  or  unusual  articles  of  food,  are  not 
unusual  accompaniments  of  pregnancy.  Occasionally  patients  are 
seen  who  enjoy  better  digestion  and  even  better  general  health 
while  they  are  pregnant  than  at  any  other  time. 

The  Breasts. — A  sensation  of  weight  and  fullness  in  the  breasts, 
often  accompanied  by  tingling  sensations,  is  common  to  pregnancy, 
and  patients  who  are  observant  note  greater  prominence  of  the 
nipples,  and  enlargement  of  the  follicles  in  the  darkened  areolsc. 

Leucorrhea. — There  is  a  marked  increase  in  vaginal  discharge 
during  pregnancy.  This  is  noted  early  with  the  occurrence  of  the 
engorgement  of  the  genitals;  but,  of  course,  leucorrhea  may  be  due 
to  other  causes.  It  is  seldom  that  the  increase  in  the  discharge  in 
early  pregnancy  is  enough  to  attract  the  patient's  attention. 

Bladder  Disturbances. — Increased  frequency  of  micturition  is  a 
most  common  accompaniment  of  early  pregnancy,  probably  due  to 
congestion  of  the  vesical  trigone  coincident  with  the  physiological 
hypercmia  of  the  uterine  organs. 

Inspection  and  Palpation 

Since  the  days  of  Hippocrates  and  Democritus  certain  changes 
in  the  face  and  neck  have  been  observed  in  pregnant  women.  The 
eyes  seem  to  be  deeper  set,  and  may  have  bluish  circles  under 
1hem;  there  are  brownish-yellow  blotches  upon  the  skin  of  the 
cheeks,  which  are  fuller  than  usual,  and  the  neck  seems  larger  than 
when  the  woman  is  not  pregnant.  Too  much  importance  is  not  to 


FIRST  THREE  MONTHS  OF  PREGNANCY  421 

be  attached  to  these  signs,  which  may  be  entirely  absent.  Still, 
one  or  more  of  the  changes  will  be  found  not  infrequently  if  oppor- 
tunity is  afforded  for  careful  observation  of  the  patient  both  before 
and  during  pregnancy. 

The  Breasts. — Enlargement. — The  breast  enlargement  of  preg- 
nancy presents  a  firm,  irregular  feeling  on  palpation,  and  not  the 
smooth,  soft  swelling  due  to  increase  of  fatty  tissue.  The  hard, 
knotty  sensation  is  due  to  the  increase  in  the  size  and  number  of 
the  lobules  of  the  mammary  gland.  In  the  early  months  this  change 
is  to  be  distinguished  most  clearly  at  the  outer  edges  of  the  gland. 

The  veins  of  the  entire  breast  are  enlarged,  forming  a  blue  tra- 
cery under  the  skin,  most  marked  in  the  neighborhood  of  or  in  the 
areola.  They  show  better  in  persons  with  white,  thin  skins. 

The  Areola. — The  circular  area  upon  which  the  nipple  stands  in  the 
non-pregnant  woman,  of  a  pinkish  or  somewhat  pigmented  color 
according  to  the  type  of  the  individual,  darker  in  brunettes  and 
lighter  in  blondes,  under  the  influence  of  gestation  becomes  darker 
in  color.  Even  in  the  light  blonde  the  customary  pink  color  is 
deepened ;  in  the  brunette  the  areola  becomes  the  color  of  the  skin 
of  a  quadroon.  In  fair  women  the  areola  may  be  elevated  above 
the  surrounding  skin;  this  feature  is  brought  into  prominence  by 
stretching  the  skin  of  the  rest  of  the  breast.  When  stimulated  by 
a  touch  of  the  finger  tip  the  surface  of  the  areola  will  wrinkle  up  or 
pucker.  The  wrinkling  brings  into  prominence  the  enlarged  se- 
baceous follicles,  some  twelve  to  twenty  in  number,  which  project 
about  a  sixteenth  of  an  inch  above  the  surface  of  the  areola. 

The  value  of  the  mammary  signs  is  greater  in  first  pregnancies 
because  many  of  the  characteristics,  such  as  enlargement  and  the 
appearances  of  the  areola,  persist  after  the  termination  of  the 
first  pregnancy.  One  must  rule  out  previously  existing  uterine  or 
ovarian  disorders,  or  masturbation,  because  in  these  conditions 
the  breast  appearances  are  often  the  same  as  in  pregnancy.  The 
mammary  signs  are  among  the  earliest  of  the  indications  of  preg- 
nancy and  are  especially  valuable  as  indicative  of  the  probable 
condition  in  the  case  of  the  unmarried  where  it  is  necessary  for 
the  physician  to  proceed  with  caution.  A  physical  examination  of 
the  chest  gives  opportunity  to  inspect  the  breasts,  and  their  showing 
sometimes  warrants  further  investigation. 

Inspection  of  the  Vulva  and  Vagina. — On  separating  the  labia  the 


422  NORMAL   UTERINE   PREGNANCY 

vagina  will  be  found  to  be  abnormally  moist  and  covered  with 
whitish  shreds  of  desquamated  epithelium,  and  the  anterior  vag- 
inal wall  just  under  the  urethra  shows  a  dusky,  purplish  discolora- 
tion sometimes  called  Jacquemin's  sign  because  first  noted  by  this 
author  in  1837.  The  discoloration  is  to  be  seen  first  in  the  bottoms 
of  the  furrows  of  the  mucous  membrane,  therefore  it  is  well  to  put 
the  anterior  vaginal  wall  on  the  stretch.  This  sign  may  be  apparent 
as  early  as  the  end  of  the  first  month  and  is  present  in  over  half  of 


soft 


FIG.   177. — Diagrammatic  Side  View  of  the  Pregnant  Uterus  of  the  Sixth  Week, 
during  Relaxation.     (After  Dickinson.) 

all  cases  by  the  end  of  the  third  month.    It  is  more  distinct  in  mul- 
tipart and  is  more  apt  to  be  absent  in  primipane. 

Six'culum  examination  of  the  upper  vagina  shows  the  cervix  to 
be  of  a  purplish  color,  soft  to  the  feel,  and  in  primiparip  the  os 
tinea'  becomes  rounder.  Erosions  are  of  a  deeper  purple  color  than 
the  surrounding  tissues.  Many  observers  consider  the  discoloration 
of  the  cervix  an  earlier  and  more  constant  sign  than  Jacquemin's 
sign.  As  congestion  of  vagina  and  cervix  may  be  found  in  pelvic 
disease,  such  as  large  ovarian  and  uterine  tumors  obstructing  the 
venous  circulation,  and  in  certain  constitutional  diseases,  as  heart 


FIRST  THREE  MONTHS  OF  PREGNANCY  423 

disease  and  cirrhosis,  the  physician  must  be  on  his  guard.  The 
typical  discoloration  of  pregnancy  is,  however,  limited  to  the  lower 
anterior  vaginal  wall,  about  the  lower  urethra,  and  to  the  cervix; 
whereas  in  pelvic  disease  and  constitutional  disorders  the  con- 
gestion is  general. 

The  Bimanual  Touch. — This  is  practised  with  the  patient  in  the 
customary  dorsal  position  (see  page  33).  The  finger  notes  a  soft 
cervix.  It  is  to  be  remembered  that  softening  of  the  cervix  is 


FIG.  177 a. — The  same,  during  Contraction. 

found  also  in  septic  conditions  of  the  uterus,  as  in  septic  endome- 
tritis,  so  that  a  soft  cervix  is  not  pathognomonic  of  pregnancy. 
The  uterus  itself  is  a  little  lower  in  the  pelvis  than  normal,  and  is 
enlarged  by  the  growing  ovum,  which  is  usually  attached  to  the 
endometrium  in  the  neighborhood  of  the  orifices  of  the  tubes.  The 
uterus  grows  faster  than  the  ovum  at  first,  and  the  ovum  with 
its  envelopes  does  not  fill  the  uterine  cavity  until  the  end  of  the 
third  month,  when  the  decidua  reflexa  joins  the  decidua  vera. 

The  first  change  in  shape  noted  in  the  gravid  uterus  consists  in 
a  slight  enlargement  of  its  transverse  diameter;  then  it  becomes 
lengthened  and  fatter  as  the  ovum  increases  in  size,  especially  in 


424 


NORMAL   UTERINE   PREGNANCY 


the  anterior  part  of  the  body  of  the  uterus;  this  anterior  bulging 
being  quite  characteristic  in  many  cases.  Asymmetry  is  caused 
by  the  development  of  the  ovum  in  one  cornu,  a  not  uncommon 
happening.  Uterine  enlargement  may  be  detected  by  the  practised 
hand  as  early  as  the  sixth  week;  in  the  third  month  there  can  be 
no  doubt  about  it,  even  to  the  tyro.  The  softening  of  the  uterus 
varies  in  different  individuals  and  at  different  times  in  the  same 
individual.  It  is  less  in  primiparse  than  in  multipart,  but  under 


FIG.  178. — Six-weeks'  Pregnant  Uterus  with  Elongation  of  Cervix,  Showing 
Extent  to  which  its  Cavity  Is  Occupied  by  the  Ovum.  O.K.,  external  os;  O.I., 
internal  os;  D.V.,  decidua  vera;  D.S.,  decidua  serotina;  D.R.,  decidua  reflexa; 
Kml).,  embryo;  P.,  placenta.  (Williams.) 

the  influence  of  pregnancy  there  is  always  an  increase  in  elasticity  of 
the  organ.  Even  as  early  as  the  first  weeks  the  rhythmical  contrac- 
tions which  go  on  throughout  pregnancy  may  be  felt  by  patient 
bimanual  palpation.  They  involve  the  entire  uterus  and  are  ex- 
cited by  any  manipulation  of  the  organ,  therefore  the  bimanual 
examination  should  last  from  five  to  ten  minutes  so  that  sufficient 
time  may  be  afforded  for  contractions  to  take  place.  Ellice  Mc- 
Donald (Amer.  Jour.  Obstct.,  LYIL,  1908)  observed  intermittent 


FIRST  THREE  MONTHS  OF  PREGNANCY 


425 


contractions  in  88  out  of  100  cases  of  early  pregnancy  examined 
with  reference  to  diagnosis.  The  lower  uterine  segment  is  the 
portion  of  the  uterus  where  the  softening  is  most  manifest.  The 
softening  at  this  point  is  called  Hegar's  sign  and  can  be  determined 
only  during  uterine  relaxation.  The  upper  portion  of  the  uterus, 
being  occupied  by  the  ovum,  is  tense  and  elastic ;  below  the  ovum 
the  soft  uterine  tissues  may  be  compressed  between  the  finger  in 


FIG.  179.— Bimanual  Palpation  of  Early  Pregnancy  for  Hegar's  Sign.    (Williams.) 


the  vagina  and  the  fingers  of  the  abdominal  hand  brought  down 
either  in  front  of  the  uterus  or  behind  it,  generally  the  latter. 
(See  Fig.  179.) 

Very  early  in  pregnancy  palpation  with  the  abdominal  hand  in 
front  of  the' body  of  the  uterus  and  the  vaginal  finger  behind  the 
cervix  is  sometimes  available,  especially  in  cases  of  retroversion ; 
later  in  pregnancy,  when  the  uterus  has  become  longer  and  more 


426  NORMAL   UTERINE   PREGNANCY 

anteflexed,  the  fingers  of  the  abdominal  hand  are  brought  down 
behind  the  fundus,  while  the  finger  in  the  vagina  is  placed  in  front 
of  the  cervix.  The  softening  of  the  tissues  of  the  lower  uterine 
segment  makes  this  portion  of  the  uterus  more  flexible  than  in  the 
unimpregnated  state.  Downward  pressure  by  the  abdominal  hand 
on  the  top  of  the  fundus  during  a  period  of  relaxation,  while  the 
vaginal  finger  under  the  crown  of  the  cervix  makes  upward  pressure, 
causes  the  uterus  to  bend  in  the  weakest  part,  the  softened  area. 
McDonald  found  this  increased  flexibility  in  ninety-seven  out  of  his 
one  hundred  cases. 

DURING  THE  LAST  Six  MONTHS  OF  PREGNANCY 
History 

The  history  is  the  same,  except  that  nausea  and  vomiting  and 
digestive  disturbances  cease  after  the  third  month,  and  the  bladder 
symptoms  are  apt  to  be  less.  Abdominal  enlargement  is  noticeable 
now,  and  the  patient  has  to  let  out  her  dresses.  Quickening,  or  the 
sensation  caused  by  the  fetal  movements,  is  felt  from  the  sixteenth 
to  the  eighteenth  week  of  gestation,  some  women  detecting  it 
earlier  than  others. 

Inspection  and  Palpation 

The  Gait. — In  the  later  months  the  pregnant  woman  walks  with 
a  backward  pose,  the  abdomen,  more  or  less  enlarged,  being  prom- 
inent in  front.  Ask  her  to  walk  up  and  clown  the  office  and  note 
her  gait.  Also,  the  sacro-iliac  and  pubic  joints  of  the  pelvis  are 
relaxed  during  later  pregnancy;  in  women  with  sacro-iliac  disease 
the  motion  is  excessive,  and  the  gait  is  decidedly  wobbly;  in  other 
women  the  gait  may  be  little  if  any  affected. 

The  Figure. — The  prominent  breasts  and  protuberant  abdomen 
will  be  noticeable  if  the  physician  has  been  acquainted  with  his 
patient  previous  to  pregnancy. 

The  Breasts. — Besides  the  changes  in  the  breasts  noted  as  to  be 
found  during  the  first  three  months,  there  appears  at  the  fifth  month 
a  secondary  areola  outside  the  primary  areola  which  is  next  to  the 
nipple,  consisting  of  a  network  of  pigment  around  light  spots, 
each  spot  representing  a  circle  round  the  opening  of  a  sebaceous 
follicle.  These  light  spots  may  extend  all  over  the  breasts,  but  are 


LAST  SIX  MONTHS  OF  PREGNANCY  427 

most  marked  next  to  the  primary  areola.  Skillful  stroking  of  the 
breast  toward  the  nipple  will  force  colostrum  from  the  nipple  after 
the  third  month.  This  is  a  valuable  sign  of  pregnancy,  although 
milk  has  been  found  in  the  breasts  of  virgins  and  even  in  young 
children  of  precocious  development. 

The  Vulva. — The  vulva,  vagina,  and  cervix  have  the  same  ap- 
pearance as  during  the  first  three  months,  except  that  the  engorge- 
ment of  the  tissues  is  now  more  marked.  The  vaginal  discharge  is 
increased  in  amount. 

The  bimanual  touch  detects  the  fetus  by  internal  ballottement 
after  the  fourth  month,  for  by  this  time  the  quantity  of  liquor 

I 


FIG.  180. — Primary  and  Secondary  Areolae  in  a  Brunette.    ("American 
Text-Book  of  Obstetrics.") 

amnii  is  sufficient,  and  the  fetus  is  large  enough  to  permit  the 
examiner  to  feel  its  bobbing  about  in  the  uterus.  Ballottement 
may  be  practiced  with  the  patient  in  the  dorsal  or  in  the  standing 
position,  preferably  the  latter.  The  physician  introduces  one  or 
two  fingers  into  the  vagina  and  makes  a  quick,  sharp,  upward 
push  against  the  uterus.  In  a  moment  the  fetus,  which  is  heavier 
than  the  fluid  in  which  it  is  suspended,  settles  against  the  examin- 
ing finger  with  a  distinct  tap.  This  sign  is  available  during  the 
fifth  and  sixth  months.  After  that  the  fetus  has  grown  so  large 
that  it  can  not  be  moved  about  freely.  After  the  seventh  month 
the  cervix  is  very  soft  and  the  os  is  patulous. 

The  Abdomen. — Pig-mentation  of  the  linea  alba  of  the  abdomen 
is  noticeable,  especially  in  brunettes,  after  the  third  month.  It 
consists  of  a  dark  line  about  half  an  inch  wide  extending  from  the 


42S 


NORMAL   UTERINE   PREGNANCY 


symphysis  pubis  around  the  navel  to  the  tip  of  the  ensiform  car- 
tilage1. In  the  later  months  of  pregnancy  streaks  of  white  or  pink 
appear  in  the  skin  of  the  flanks,  the  breasts,  and  the  lower  abdomen, 
the  so-called  lineie  albicantes. 

The  protrusion  of  the  abdomen  in  pregnancy  after  the  fifth  or 
sixth  month  is  generally  asymmetrical,  being  more  marked  on  the 
right.  The  umbilicus  is  apt  to  protrude  in  the  last  two  months. 


FIG.  181. — Enlargement  of  the  Uterus  at  the  Different  Weeks  of  Pregnancy. 
("American  Text-Book  of  Obstetrics.") 

The  fundus  uteri  is  two  or  three  fingers'  breadth  above  the  sym- 
physis at  the  end  of  the  fourth  month  and  reaches  the  umbilicus 
at  the  close  of  the  sixtli  month. 

The  parts  of  the  fetus  may  be  felt  in  favorable  cases  by  the 
twentieth  week  (the;  fifth  month),  being  a  most  valuable  sign  of 
pregnancy.  Excess  of  liquor  amnii,  a  rigid  and  thick  abdominal 


LAST  SIX  MONTHS  OF  PREGNANCY  429 

wall,  or  tense  uterine  walls  prevent  the  detection  of  the  fetal  parts. 
Fetal  movements  can  be  felt  by  the  end  of  the  sixth  month  with  a 
fair  degree  of  constancy  and  often  much  earlier.  Placing  the  hand 
quietly  on  the  abdomen  it  is  allowed  to  rest  there  for  several  min- 
utes. A  very  gentle  throb  is  felt  if  in  the  sixth  month,  later  the 
movements  are  stronger.  During  the  sixth  month  external  ballotte- 
ment  may  be  practised,  a  hand  on  each  side  of  the  abdomen  being 
able  to  push  the  fetus  to  and  fro;  also  intermittent  uterine  con- 
tractions, rhythmic  and  painless,  occurring  every  five  to  ten 
minutes  and  lasting  a  minute  or  two,  may  be  distinguished  by 
placing  the  hand  on  the  abdomen  and  waiting.  A  sudden  motion 
with  the  hand  or  a  cold  hand  will  often  cause  a  contraction.  These 
contractions  can  be  made  out  through  the  abdomen  after  the 
fourth  month,  but  are  to  be  felt  by  bimanual  touch  from  the  begin- 
ning of  pregnancy.  A  uterus  distended  by  retained  menstrual 
blood  or  by  an  intra-uterine  tumor  has  these  same  rhythmical 
contractions. 

Auscultation 

The  fetal  heart  sounds  are  proof  positive  of  pregnancy.  Oc- 
casionally they  may  be  heard  toward  the  end  of  the  fourth  month, 
but  as  a  rule  are  not  available  as  a  means  of  diagnosis  before  the 
end  of  the  fifth  month.  The  entire  anterior  surface  of  the  uterus 
must  be  explored  with  the  stethoscope  because  of  the  variable 
position  of  the  fetus,  but  the  most  usual  situation  is  between  the 
umbilicus  and  the  left  anterior  superior  spine  of  the  ilium,  because 
the  back  of  the  child  is  situated  there  in  the  commonest  position, 
left  occipito-anterior.  The  heart  beat  has  been  likened  to  the 
ticking  of  a  watch  under  a  pillow;  it  is  double  and  has  a  rate  of 
120  to  150  beats  a  minute,  being  increased  by  the  activity  of  the 
child,  by  fever  of  the  mother,  and  at  the  begining  of  a  uterine 
contraction,  variations  of  twenty  beats  a  minute  being  often 
observed  in  the  same  fetus.  A  uterine  souffle,  synchronous  with  the 
mother's  pulse  and  heard  best  along  the  left  side  of  the  uterus, 
becomes  audible  during  the  fourth  month  and  is  a  sign  of  an  en- 
larged uterus,  but  not  necessarily  of  pregnancy  because  it  is  heard 
also  in  large  fibroids. 

A  summary  of  the  symptoms  and  signs  of  pregnancy  by  months, 
modified  from  Dickinson,  is  appended. 


430 


NORMAL   UTERINE   PREGNANCY 


SUMMARY  OF  SYMPTOMS  AXD  SIGNS  OF  PREGNANCY  BY  MONTHS. 


Calendar 
Months. 

HISTORY. 

BREASTS. 

ABDOMEN. 

PELVIS. 

MISCELLANEOUS 

1 

\  in  en  or  rh  on 

2 

throughout 
all  months. 

Nausea.  Swell- 

Enlarged. 

Leucorrhea. 

3 

ing  and  t  i  ti- 
ff 1  i  M  g     of 
breasts. 
Frequency 
of   micturi- 
tion. 

Ditto 

Veins  show. 
Areola  pig- 
m  e  n  t  e  d. 
Follicles. 

Ditto 

Purplish 
discolora- 
tion vagina. 
Bulging  an- 
terior   fun- 
dus.     Com- 
pressibility 
of  lower  seg- 
ment.   Soft 
cervix. 

Ditto   

Swelling  of  face 

4. 
5 

Nausea  ceases. 
Quickening  .  . 

Colostrum.  .  .  . 
Secondary 

Beginning  en- 
largement. 
Pigmenta- 
tion of  linea 
alba. 

Fetal       heart 

Cervix  softer. 
Fetal  parts 
felt.      More 
congestion 
of  vagina. 

Internal    bal- 

and  neck. 

Skin    discol- 
orations. 

fi 

Ditto  

areola. 
Ditto 

sounds 
heard.  Fetal 
parts  felt. 
Uterine 
contrac- 
tions      felt. 
Uterine 
souffle. 

Fetal     move- 

lottement. 
Ditto 

Gait  unsteady 

7. 

Ditto  

Ditto    

ments.   Ext. 
ballotte- 
ment.    Lin- 
ea1 albicai.- 
tes.  Fundus 
reaches  um- 
bilicus. 

Ditto 

Cervix  high- 
er in       the 
pelvis. 

No     ballotte- 

Backward 
pose.  Promi- 
nent breasts 
and     abdo- 
men. 

Ditto 

8 

ment. 

9. 

gressively 
larger. 

soft  and  os 
patulous. 

DIFFERENTIAL   DIAGNOSIS  431 


DIFFERENTIAL  DIAGNOSIS  OF  NORMAL  PREGNANCY 

It  has  been  my  experience  that  in  early  pregnancy  a  malfor- 
mation of  the  uterus  or  a  tumor  of  the  uterus  is  most  often  mistaken 
for  pregnancy,  whereas  in  the  later  months  an  ovarian  tumor  is 
frequently  confused  with  the  pregnant  uterus.  It  may  be  well  to 
mention  some  of  the  most  common  mistakes  in  diagnosis,  although 
there  are  so  many  that  the  advice  as  to  the  later  months  to  regard 
all  enlargements  of  the  abdomen  as  due  to  pregnancy  until  the 
contrary  has  been  proven,  is  certainly  safe  to  follow. 

During  the  First  Three  Months 

Anteflexionwith  retroposition  may  closely  simulate  early  pregnancy, 
especially  if  there  is  congestion  of  the  cervix  and  an  endometrial 
discharge.  In  anteflexion  the  cervix  is  not  soft,  there  is  no  purplish 
discoloration  of  the  anterior  vagina,  the  corpus  uteri  is  not  elastic, 
the  lower  uterine  segment  is  not  compressible,  there  are  no  rhyth- 
mical contractions,  and  menstruation  still  persists,  though  irregular. 
An  examination  several  weeks  later  shows  the  signs  to  be  the  same 
as  at  the  last  examination,  and,  additionally,  markedly  anteflexed 
uteri  are  generally  sterile. 

Chronic  subinvolution  shows  an  enlarged  uterus,  but  the  tissues 
are  firmer  than  normal,  the  body  is  not  globular  in  shape  or  bulging 
anteriorly,  and  the  lower  uterine  segment  is  not  compressible. 
Purplish  discoloration  is  absent.  Menstruation,  though  scanty, 
is  present. 

Fibroid  of  the  anterior  wall  is  of  hard  consistency;  menstruation 
is  present,  purplish  discoloration  is  absent,  rhythmical  contrac- 
tions may  be  present.  Upon  a  second  examination  after  an  interval 
of  two  weeks  or  more,  the  sound  may  be  passed  and  the  situation 
and  size  of  the  fibroid  determined. 

Retroflexion. — The  congested  fundus  may  simulate  a  gravid 
uterus.  The  uterus  should  be  replaced  as  described  in  Chapter 
XIV.,  page  237,  and  another  examination  made  in  the  course  of  a 
few  days. 

Extra-uterine  pregnancy  is  considered  in  Chapter  XIX.,  page  340. 

It  is  always  wise  not  to  hurry  in  making  a  diagnosis  in  doubtful 
cases  and  ask  for  another  examination,  if  necessary  with  an  anes- 


432  ABNORMAL   UTERINE   PREGNANCY 

thctic.    Nothing  is  to  bo  lost  and  often  much  gained  by  adopting 
such  a  course. 

During  the  Last  Six  Months 

In  the  case  of  enlargements  of  the  abdomen  due  to  other  causes 
than  pregnancy  the  rate  of  enlargement  does  not  coincide  with 
that  of  the  gravid  uterus;  if  amenorrhea  is  present  the  duration 
of  the  absence  of  the  menses  does  not  correspond  with  the  size  of 
the  tumor,  supposing  it  to  be  pregnancy;  and  the  distinctive  signs 
of  pregnancy  are  absent,  namely,  the  fetal  heart  sounds,  fetal  parts 
felt,  fetal  movements  felt,  and  internal  and  external  ballottement. 
Menstruation  usually  persists.  The  differential  diagnosis  of  ova- 
rian cysts,  fibroid  tumors,  phantom  tumors,  and  fat  in  the  abdom- 
inal wall,  distended  bladder,  ascites,  tympanites,  and  the  very 
rare  hcmatometra,  will  be  found  in  the  chapter  devoted  to  those 
subjects  as  shown  in  the  index  and  need  not  be  repeated  here.  In 
cases  of  rigid  abdominal  walls  more  than  one  examination  and, 
in  very  doubtful  cases,  an  anesthetic  is  indicated. 


THE  DIAGNOSIS  OF  ABNORMAL  UTERINE  PREGNANCY 

The  Diagnosis  of  Retroflexion  and  Incarceration  of  the  Pregnant 
Uterus. — This  not  uncommon  condition  is  characterized  by  a 
tumor  of  elastic  consistency  filling  the  pelvis,  the  cervix  being  high 
up  behind  the  arch  of  the  pubes.  The  symptoms  and  signs  of 
pregnancy  are  present  and  in  addition  there  arc  apt  to  be  pelvic 
pains  and  retention  of  urine.  Before  attempting  to  replace  the 
uterus  a  careful  investigation  of  the  urinary  function  should  be 
made  and  queries  asked  whether  there  has  been  stoppage  of  urine 
or  whether  any  bits  of  tissue  have  been  passed  with  the  urine,  or 
the  patient  has  suffered  with  symptoms  of  cystitis.  Krukcnberg, 
who  with  Rivington  collected  twenty  cases  of  rupture  of  the 
bladder  occurring  in  cases  of  incarcerated  retroflexed  pregnant 
uteri,  advises  against  replacement  of  the  uterus  whenever  there 
have  been  passed  by  the  urethra  portions  of  necrotic  bladder  wall 
because  of  the  danger  of  rupturing  the  bladder  during  replace- 
ment. He  prefers  to  practice  abortion.  In  any  event  the  bladder 
should  be  thoroughly  emptied  by  catheter  before  attempts  at 


INTERSTITIAL  PREGNANCY  433 

replacement  are  carried  out.  These  are  done  by  placing  the  patient 
in  the  knee-chest  position,  making  traction  on  the  cervix  with  a 
tenaculum  and  at  the  same  time  rocking  the  fundus  upward  by 
the  promontory  of  the  sacrum  by  pressure  on  the  uterus  through 
the  abdomen.  Often  the  Sims  position  is  more  favorable  for  this  pro- 
cedure, and  sometimes  it  will  be  necessary  to  pack  the  vagina  with 
cotton  tampons  and  make  a  second  attempt  after  an  interval  of 
forty-eight  hours.  In  my  experience  the  administration  of  an 
anesthetic  is  seldom  necessary. 

The  Diagnosis  of  Interstitial  Pregnancy  and  of  Pregnancy  in  a 
Rudimentary  Horn  of  a  Bicornute  Uterus. — In  Chapter  XIII.,  page 
198,  are  described  the  different  sorts  of  anomalies  of  the  uterus. 
E.  Kehrer  ("Das  Nebenhorn  des  doppelten  Uterus,"  1899)  col- 
lected eighty-two  cases  of  pregnancy  in  rudimentary  cornua.  The 
diagnosis  before  operation  in  a  majority  of  these  cases  lay  between 
extra-uterine  pregnancy,  ovarian  cyst  and  subserous  myoma. 
The  diagnosis  of  this  condition  intra  vitam  must  always  be 
considered  extremely  difficult.  Kehrer  cites  five  physicians  who 
diagnosed  the  condition  correctly  and  reports  the  cases  in  detail. 
The  chief  point  of  difference  between  tubal  pregnancy  and  preg- 
nancy in  the  rudimentary  horn  of  a  uterus  bicornis  is  that  in  the 
latter  there  is  a  thick  pedicle  or  even  no  pedicle  at  all  between  the 
uterus  and  the  gravid  tumor,  whereas  in  extra-uterine  pregnancy 
there  is  a  long  slim  pedicle,  longer  in,  ampullar  and  isthmial  tubal 
pregnancy  and  shorter  in  interstitial  tubal  pregnancy. 

Interstitial  pregnancy  often  simulates  pregnancy  in  a  rudimentary 
horn.  The  ovum  developing  in  the  uterine  portion  of  the  tube  causes 
asymmetry  of  the  uterus.  Only  when  the  conditions  for  examina- 
tion are  most  favorable  can  the  separation  between  the  pregnant 
horn  and  the  main  fundus  uteri  be  felt.  The  sound  may  be  passed 
into  the  main  uterine  cavity  to  prove  that  it  is  empty.  I  have 
seen  two  cases  of  interstitial  pregnancy  that  became  normal  uterine 
pregnancies  in  the  course  of  the  third  month  as  the  fetus  and  its 
envelopes  grew  into  the  uterine  cavity  from  the  tube.  As  a  rule 
the  interstitial  pregnant  tumor  is  separated  from  the  uterus  by  a 
shorter  pedicle  than  the  pregnant  rudimentary  horn  of  a  double 
uterus. 

The  Diagnosis  That  Pregnancy  Has  Occurred  Previously. — In  medi- 

colegal  cases  the  physician  may  be  called  upon  to  give  an  opinion 

28 


434  ABNORMAL   UTERINE    PREGNANCY 

whether  or  no  a  woman  has  ever  borne  a  child.  The  answer  will 
depend  upon  the  physical  examination  alone.  Following  preg- 
nancy the  breasts  arc  flabby  and  more  or  less  pendulous,  the 
changes  in  the  nipples  and  areolsc  previously  described  are  to  be 
sought,  also  linear  albicantes  on  the  breasts  or  about  the  lower 
abdomen  or  hips.  A  scar  from  a  mammary  abscess  is  good  evidence 
of  previous  lactation  unless  other  satisfactory  explanation  of  its 
presence  is  forthcoming. 

By  vaginal  examination  the  hymen  will  be  found  destroyed  and 
in  its  place  the  carunculai  myrtiformes,  the  vagina  will  show  a 
certain  amount  of  relaxation  and  absence  of  the  ruga3;  lacerations 
of  the  perineum  or  pelvic  floor  are  proof  of  previous  pregnancy. 
The  uterus  will  be  found  a  little  enlarged  and  the  os  will  be  found 
round,  not  the  os  tinea?  of  virginity.  A  tear  in  the  cervix  is  proof 
positive  of  child-bearing  unless  there  is  a  history  of  instrumentation. 
Erosions  with  endocervicitis  must  not  be  mistaken  for  lacerations 
and  their  effects. 

The  Diagnosis  of  Multiple  Pregnancy. — The  diagnosis  of  multiple 
pregnancy  rests  on  finding  an  unusually  large  uterus,  a  groove  in 
the  fundus  separating  the  fetuses,  hearing  two  fetal  hearts,  each 
with  a  different  rhythm,  and  on  the  palpation  of  two  heads  or  two 
breeches. 

The  Diagnosis  of  Pernicious  Vomiting  of  Pregnancy. — Excessive 
vomiting  of  pregnancy  or  hyperemesis  gravidarum,  occurring  most 
frequently  between  the  third  and  the  fifth  week  of  pregnancy,  is 
of  three  varieties,  according  to  J.  Whitridge  Williams,  reflex,  neu- 
rotic, and  toxemic.  In  the  reflex  variety,  the  vomiting  is  apparently 
directly  attributable  to  the  existence  of  some  abnormality  of  the 
generative  tract  such  as  retroflexion  or  anteflexion  of  the  uterus, 
erosions  or  cicatrices  of  the  cervix,  or  an  ovarian  tumor,  and  it 
ceases  promptly  upon  the  correction  or  removal  of  the  abnormality. 
The  fact,  however,  that  in  many  pregnant  women  the  presence  of 
similar  lesions  is  not  associated  with  serious  vomiting  would  ap- 
parently indicate  that  its  reflex  origin  is  quite  exceptional,  and  is 
evidence  that  some  other  etiological  factor  is  usually  concerned  in 
the  production  of  the  vomiting.  The  failure  of  suggestive  treat- 
ment and  the  lack  of  evidence  of  serious  changes  in  metabolism 
make  it  improbable  that  the  affection  is  neurotic  or  toxemic  in 
origin. 


PERNICIOUS  VOMITING  OF  PREGNANCY  435 

In  the  neurotic  variety  the  vomiting  is  dependent  upon  the 
existence  of  a  neurosis — more  or  less  clearly  allied  to  hysteria — 
which  may  occur  in  women  who  had  manifested  no  signs  of  im- 
paired nervous  control  previous  to  the  occurrence  of  pregnancy. 
In  such  cases  careful  examination  will  fail  to  reveal  the  existence 
of  a  single  physical  condition  which  could  account  for  the  vomiting, 
while  the  most  accurate  chemical  analysis  of  the  urine  will  afford 
no  evidence  of  serious  metabolic  disturbance;  and,  finally,  char- 
acteristic lesions  will  not  be  found  at  autopsy  hi  the  rare  cases 
which  end  fatally,  as  such  patients  die  from  starvation. 

Cure  frequently  follows  the  employment  of  apparently  useless 
measures  and  unphysiological  procedures,  such  as  a  vigorous 
lecture  on  the  part  of  the  physician,  dilating  the  cervix,  applying 
leeches  to  the  epigastrium,  or  the  administration  of  an  anesthetic. 
A  rigorous  rest  cure  or  suggestive  treatment  also  may  bring  relief. 

Toxemic  vomiting,  on  the  other  hand,  is  a  very  serious  disease 
and  is  a  manifestation  of  a  profound  disurbance  in  metabolism,  of 
the  exact  origin  of  which  we  are  ignorant.  All  that  we  know  at 
present  is  that  it  usually  ends  in  death,  and  sometimes  leads  to  a 
fatal  termination  within  a  few  days  after  the  appearance  of  serious 
symptoms.  In  such  cases  the  patient  presents  signs  of  a  profound 
intoxication,  and  may  die  in  coma  without  any  evidence  of  star- 
vation. 

The  urine,  while  diminished  in  amount  as  the  result  of  the 
scanty  intake  of  fluids,  does  not  contain  albumin  or  casts  until 
shortly  before  death,  and  may  apparently  present  a  normal  amount 
of  urea,  as  determined  by  the  Doremus  method,  so  that  its  casual 
examination  gives  no  clew  to  the  gravity  of  the  condition. 

In  reality,  however,  there  is  a  decided  decrease  in  the  amount 
of  nitrogen  excreted  as  urea  and  a  marked  increase  in  the  amount 
put  out  as  ammonia.  Accordingly,  while  the  total  nitrogen  output 
may  be  practically  normal,  the  percentage  of  nitrogen  eliminated 
as  ammonia  is  greatly  increased,  and  this  so-called  "ammonia 
coefficient,"  instead  of  being  4  or  5  per  cent  as  in  normal  pregnancy, 
may  rise  to  20,  30,  or  40  per  cent.  Moreover,  the  proportion  of 
amido-acids  is  increased,  and  sometimes  the  acetone  content  is 
abnormally  large. 

In  making  a  differential  diagnosis  between  the  three  varieties  it 
is  essential  to  eliminate  the  toxemic  form  by  a  careful  urinary 


436  ABORTION 

analysis.  If  the  ammonia  coefficient  exceeds  10  per  cent  th'e 
diagnosis  of  toxemic  vomiting  should  be  made.  If  the  ammonia 
coefficient  is  approximately  normal  the  probability  of  a  serious 
toxemic  condition  can  be  eliminated  and  the  diagnosis  will  be 
between  the  reflex  and  the  neurotic  varieties.  Some  manifest 
lesion  in  the  generative  tract  makes  the  diagnosis  reflex  vomiting. 
The  suggestion  has  been  put  forward  by  F.  P.  Underhill  and  R. 
F.  Rand  (Archiv.  of  Internal  Medicine,  Jan.  15,  1910,  Vol.  5,  p.  61), 
that  the  changes  observed  in  the  urine  in  pernicious  vomiting  of 
pregnancy  are  induced  by  the  inanition  which  accompanies  the 
severe  grades  of  the  disease  and  that  the  urine  shows  nothing 
characteristic  until  a  stage  of  great  prostration  has  been  reached. 
They  think  that  the  supply  of  carbohydrates  to  the  system  is  the 
factor  which  determines  the  relative  output  of  urea  and  ammonia 
and  claim  good  results  in  the  treatment  of  pernicious  vomiting 
by  the  administration  by  enema  of  dextrose  in  solution. 


Definitions. — An  abortion  is  the  expulsion  from  the  uterus  of  the 
products  of  conception  before  the  placenta  is  formed,  that  is, 
during  the  first  three  months;  a  miscarriage  is  the  emptying  of 
the  uterus  of  the  fetus,  the  placenta  and  its  membranes,  from  the 
begining  of  the  fourth  month  until  the  child  is  viable,  at  the  end 
of  six  and  three-fourths  months;  and  a  premature  labor  is  the 
delivery  of  the  child  after  it  is  viable,  or  between  six  and  three- 
fourths  months  and  term. 

The  word  abortion  is  so  frequently  used  to  mean  the  expulsion 
of  the  products  of  conception  at  any  time  from  the  beginning  of 
pregnancy  up  to  the  time  of  viability  that  it  is  convenient  to  so 
use  it  in  this  chapter. 

A  complete  abortion  is  one  in  which  the  fetus  and  its  membranes 
are  cast  off  entire;  an  incomplete  abortion  is  one  in  which  the  fetus 
is  born,  but  the  membranes  and  the  placenta,  if  formed,  remain 
behind;  a  concealed  or  missed  abortion  is  one  in  which  the  embryo 
has  perished  but  is  not  expelled;  spontaneous  abortions  are  those 
which  occur  without  known  cause;  induced  abortions  arc  those 
which  arc  caused  artificially  and  intentionally,  whether  by  the 


ETIOLOGY  437 

administration  of  drugs  or  by  the  use  of  intruments,  and  habitual 
abortions  are  abortions  repeated  in  successive  pregnancies. 

Frequency. — Obviously  exact  figures  as  to  the  frequency  of 
abortions  are  difficult  to  obtain.  Without  doubt  many  occur 
during  the  first  six  weeks  of  pregnancy  without  attracting  much 
attention,  and  many  patients  who  have  abortions  are  not  under  a 
physician's  care.  J.  Clifton  Edgar  found  635  cases  of  interruption 
of  pregnancy — abortion,  miscarriage,  or  premature  delivery— 
among  10,000  cases  of  labor  treated  in  a  dispensary  service  in 
New  York  City,  or  one  in  every  15.7.  Some  authors  give  the 
frequency  of  abortions  as  once  in  every  five  or  six  cases  of  labor. 

Abortion  proper  is  more  apt  to  occur  hi  multipart,  while  mis- 
carriages and  premature  labors  are  found  more  commonly  in 
primiparse.  This  seems  to  be  due  to  the  frequency  of  uterine 
disease  in  multipart,  so  that  with  an  increasing  number  of  preg- 
nancies the  uterus  becomes  progressively  less  tolerant  and  expels 
its  contents  earlier  with  each  successive  pregnancy. 

Etiology. — The  causes  of  abortion  may  be  grouped  in  three 
classes  in  the  order  of  their  frequency:  (1)  maternal,  (2)  fetal, 
and  (3)  paternal. 

1.  The  maternal  causes  are    (a)   constitutional  and   (6)   local. 
a.  Constitutional.     Under  this  heading  are  to  be  classed  the  in- 
fectious diseases,  as  typhoid  fever,  pneumonia,  smallpox,  scarla- 
tina, cholera,  especially  if  accompanied  by  high  fever  suddenly 
developed,  and  tuberculosis  and  syphilis.    Syphilis  in  the  mother 
is  a  very  frequent  cause  of  abortion,  some  authors  going  so  far  as 
to  claim  that  it  causes  a  quarter  of  all  abortions. 

Other  causes  of  abortion  are  cardiac  diseases,  the  toxemia  of 
chronic  nephritis,  diabetes  mellitus,  lead  or  arsenic  poisoning, 
anemia  from  sudden  loss  of  blood,  the  use  of  oxytoxic  drugs,  as 
ergot,  cotton-root  bark,  quinine,  aloes,  and  tansy,  b.  Local  causes 
are  all  those  conditions  that  cause  pelvic  congestion,  such  as 
malpositions  of  the  uterus,  especially  retrodisplacements,  chronic 
endometritis,  lacerations  of  the  cervix,  and  excessive  sexual  inter- 
course. 

2.  The  causes  in  the  ovum  and  embryo  are,  anything  that  interferes 
with  the  nutrition  or  produces  the  death  of  the  fetus.     Many  of 
them  are  secondary  to  pathological  conditions  in  the  mother's 
tissues.     They  are  syphilis  of  the  decidua  or  placenta,  and  low 


438  ABORTION 

situations  of  the  placenta,  also,  less  frequently,  anomalies  of  the 
decidua  and  the  other  fetal  envelopes  or  of  the  fetus  itself,  pro- 
ducing injury  or  death.  Introducing  foreign  bodies  into  the  uterus, 
such  as  catheters  or  hatpins,  must  be  reckoned  as  local  causes. 
When  the  fetus  is  dead  it  acts  like  a  foreign  body  and  the  uterus 
expels  it.  In  exceptional  instances  the  fetus  may  be  retained  in 
the  uterus  as  long  as  two  weeks  after  its  death. 

3.  The  causes  due  to  the  father  are  chiefly  syphilis  transmitted  by 
the  spermatozoa.  Sometimes  there  arc  syphilitic  changes  in  the 
placenta  and  fetus  where  the  mother  shows  no  sign  of  the  disease. 
Other  causes  are  debility  in  the  father,  perhaps  due  to  tuberculosis, 
perhaps  to  excessive  indulgence  in  sexual  intercourse.  A  French 
author  has  cited  the  instance  of  thirty  cows  who  were  served  by 
the  same  bull  within  a  short  period  of  time.  The  fifteen  that 
were  served  first  went  to  full  term,  while  the  last  fifteen  aborted 
without  an  exception. 

Symptoms. — In  abortion  during  the  first  six  weeks  there  are 
seldom  any  prodromal  symptoms.  The  woman  may  think  she 
has  a  delayed  and  profuse  menstruation,  and  may  not  realize  that 
she  is  pregnant.  Much  blood  is  lost  and  clots  are  passed,  and  there 
may  be  pains  in  the  region  of  the  uterus.  If  she  thinks  she  is 
pregnant  and  observes  the  clots  she  will  think  that  she  has  seen 
the  fetus  in  the  "fleshy  mass"  that  she  has  passed.  The  ovum,  as 
a  matter  of  fact,  is  generally  passed  first  of  all  and  is  lost  with  the 
blood  and  clots.  In  the  case  of  a  complete  abortion  all  of  the 
embryo  and  its  envelopes  are  passed  at  once  and  there  is  very 
little  hemorrhage,  the  process  lasting  from  twenty-four  to  forty- 
eight  hours  from  the  first  hemorrhage  or  pain  until  all  symptoms 
cease.  Abortions  are  more  apt  to  be  incomplete,  portions  of  decidua 
being  left  behind,  and,  in  this  event,  hemorrhage  continues. 

In  abortion  from  the  sixth  to  the  twelfth  week  there  are  apt  to 
be  prodromal  symptoms  of  fullness  and  weight  in  the  pelvis  and 
backache,  indicating  pelvic  congestion.  At  this  time  uterine  pains 
and  hemorrhage  are  more  severe  and  constitutional  symptoms 
such  as  nausea,  pallor,  rigors,  nervousness,  and  apprehension  are 
often  marked.  After  the  third  month  the  symptoms  of  abortion 
are  more  like  those  of  labor  at  term.  The  three  stages  of  labor 
can  be  distinguished,  the  uterine  contractions  are  more  marked, 
and  there  are  strong  involuntarv  bearing-down  efforts. 


DIAGNOSIS  439 

Diagnosis. — The  diagnosis  of  abortion  depends  on  the  deter- 
mination that  the  patient  is  pregnant;  on  the  character  of  the  pain, 
indicating  uterine  contractions;  on  the  amount  and  character  of 
the  hemorrhage;  on  dilatation  of  the  cervix;  and  on  the  descent  of 
the  products  of  conception  into  or  through  the  os  uteri.  Practically 
we  are  called  on  to  distinguish  between  threatened  abortion,  in- 
evitable abortion,  and  an  abortion  partially  or  wholly  completed. 

The  Diagnosis  of  Threatened  Abortion. — First  we  get  the  history 
to  determine  the  probability  of  the  existence  of  pregnancy.  If  it 
can  be  learned  that  the  patient  has  missed  a  catamenia  twice  or 
even  once,  if  she  has  been  exposed  to  impregnation,  if  she  has 
experienced  any  disorders  of  digestion,  or  will  tell  of  swelling  of 
the  breasts,  or  frequency  of  micturition,  we  may  get  valuable  clews. 
Pain,  if  it  indicates  uterine  contractions,  is  of  a  rhythmical  char- 
acter, beginning  in  the  flanks  and  extending  to  the  pubic  region. 
The  distinct  character  of  the  pain  is  more  clearly  marked  in  mis- 
carriages than  in  abortions  proper  and  in  the  threatened  abortion 
there  is  little  or  no  pain.  Hemorrhage  is  moderate  in  amount, 
bright  in  color,  free  from  clots,  and  intermittent.  Examination 
shows  breast  changes  (see  section  on  normal  uterine  pregnancy,  p. 
421),  purplish  discoloration  of  the  vagina  and  cervix,  the  cervix 
soft,  the  os  somewhat  dilated.  The  uterus  is  enlarged,  the  fundus 
is  bulging  forward,  the  lower  uterine  segment  is  compressible,  and 
uterine  contractions  are  infrequent. 

If,  after  a  series  of  hours,  the  symptoms  abate  and  the  cervical 
canal  does  not  dilate,  the  ovum  does  not  descend,  and  uterine  con- 
tractions are  still  of  infrequent  occurrence,  the  case  may  be  said 
to  be  in  the  category  of  a  threatened  abortion. 

The  Diagnosis  of  Inevitable  Abortion. — If,  on  the  other  hand,  the 
hemorrhage  increases  in  amount,  is  persistent,  and  contains  clots 
and  fragments  of  fetal  structures,  pain  is  considerable  and  increas- 
ing in  severity,  and  local  examination  shows  that  the  ovum  has 
moved  down  in  the  uterus,  as  attested  by  the  elimination  of  the 
angle  of  anteflexion  between  the  large  anterior  fundus  and  the 
cervix,  while  the  ovum  can  be  felt  by  the  tip  of  the  examining 
finger  through  the  dilated  os  as  a  soft  bag,  uterine  contractions 
being  frequent,  the  case  is  one  of  inevitable  abortion. 

An  ovum  may  be  differentiated  from  a  blood  clot  by  noting 
that  it  increases  in  size  during  a  uterine  contraction,  becomes 


440  ABORTION 

smooth  and  tense,  and  advances,  while  the  blood  clot  is  not  tense 
and  does  not  advance;  also,  the  ovum  presents  a  convex  surface  and 
is  elastic,  while  the  blood  clot  is  cone-shaped  with  its  apex  down- 
ward and  is  not  elastic.  All  clots  or  tissue  passed  should  be  floated 
out  in  water  and  examined  with  a  magnifying  glass  for  decidua, 
fringe-like  chorionic  tissue,  or  bits  of  placenta,  the  tissue  being 
examined  subsequently  under  the  microscope. 

The  Diagnosis  of  Abortion  Partially  or  Wholly  Completed. — To 
determine  whether  all  or  a  part  of  the  contents  of  the  uterus  have 
been  expelled  it  is  necessary  to  have  everything  which  has  been 
passed  from  the  vulva  preserved  for  careful  inspection.  To  this 
end  the  napkins  worn  by  the  patient  should  be  saved,  and,  before 
emptying  the  bladder  or  bowels  she  should  sit  on  a  chamber  and 
strain  so  that  the  contents  of  the  vagina  may  be  expelled  into 
the  chamber  for  preservation.  The  ovum,  being  small  and  sus- 
pended in  the  liquor  amnii,  is  usually  lost  when  the  membranes  are 
ruptured  early  in  the  course  of  an  abortion,  being  passed  from  the 
vagina  at  stool.  Parts  of  the  decidua  are  more  often  left  in  the 
uterus  than  not.  In  very  early  abortions  the  pieces  of  tissue  can 
be  felt  with  the  tip  of  the  uterine  sound  palpating  the  uterine 
cavity.  When  there  is  any  foreign  substance  in  the  uterus  the 
cervical  canal  will  be  found  open.  In  pregnancy  exceeding  three 
months'  duration  the  finger  can  be  passed  into  the  uterine  cavity  and 
will  feel  the  bits  of  fetal  membranes  or  portions  of  placenta  still  ad- 
herent to  the  walls.  The  Emmett  curette  forceps  will  bring  away 
tissue  for  examination.  If  the  tissues  appear  to  be  in  any  respect 
abnormal  they  should  be  sent  to  the  pathologist  for  examination. 
The  finding  of  an  intact  ovum  settles  the  question  of  a  complete 
abortion.  The  disappearance  of  the  secretion  of  the  breasts  is  an 
important  sign  that  an  abortion  is  coriiplete.  If  the  abortion  is 
completed  the  uterus  will  be  found  contracted  and  the  uterine  canal 
closed.  In  missed  abortion  the  dead  fetus  may  be  retained  in  the 
uterus  for  some  time;  there  are  no  pain  and  no  hemorrhage,  but 
the  cervix  remains  soft  and  the  os  patulous. 

The  Diagnosis  of  Miscarriage. — The  diagnosis  of  miscarriage  is 
generally  easier  than  that  of  abortion  because  the  signs  of  pregnancy 
are  definite  and  pronounced  and  the  same  may  be  said  of  the 
symptoms  (see  the  diagnosis  of  normal  uterine  pregnancy,  page  426). 

Differential   Diagnosis. — Abortion   must    be   differentiated   from 


HYDATIDIFORM  MOLE  441 

extra-uterine  pregnancy  and  from  menorrhagia,  metrorrhagia, 
and  dysmenorrhea.  In  abortion  the  hemorrhage  is  generally 
greater  in  amount  and  the  clots  are  more  frequently  passed  than 
hi  early  extra-uterine  pregnancy  after  rupture;  the  pain  is  much 
less  severe  in  abortion  and  is  of  the  uterine  contracture  variety, 
that  is,  beginning  as  an  aching  in  the  flanks  and  radiating  to  the 
hypogastrium,  whereas  hi  extra-uterine  pregnancy  the  pain  is 
severe,  agonizing,  and  in  the  beginning  is  unilateral.  The  changes 
in  the  uterus  are  more  marked  in  abortion  than  in  extra-uterine 
pregnancy,  and  in  the  latter  some  tumor  of  the  adnexa  can  be 
determined.  It  is  to  be  remembered  that  a  uterine  decidua  is 
formed  in  the  case  of  extra-uterine  pregnancy  and  this  is  apt  to  be 
passed  early. 

Menorrhagia  and  metrorrhagia  are  excluded  by  the  history, 
which  excludes  pregnancy,  and  by  the  absence  of  the  symptoms 
and  signs  of  pregnancy,  also  by  determining  some  cause  for  the 
increased  flowing,  such  as  a  fibroid  tumor,  endometritis,  or  cancer. 
Dysmenorrhea  is  excluded  by  the  past  history  of  pain  occurring  at 
some  definite  interval  of  time  before,  after,  or  during  the  flow,  and 
by  the  absence  of  the  symptoms  and  signs  of  pregnancy. 


THE  DIAGNOSIS  OF  HYDATIDIFORM  MOLE 

Hydatidiform  mole,  also  called  vesicular  or  cystic  mole,  is  a  dis- 
ease of  the  chorion  consisting  of  a  cystic  formation  at  the  ends  of 
the  villi,  producing  a  mass  that  resembles  a  bunch  of  grapes.  It  is 
a  rare  disease  occurring  once  in  about  three  thousand  cases  of  preg- 
nancy and  is  found  oftenest  among  multiparse  between  the  ages  of 
twenty-five  and  forty.  It  is  apt  to  be  repeated  in  successive  preg- 
nancies in  the  same  patient.  The  mole  generally  develops  before 
the  fourth  month  and  causes  the  death  of  the  fetus. 

Pathology. — The  cystic  process  which  involves  the  chorion 
is,  according  to  Marc-hand,  an  edematous  degeneration  in  which 
the  syncytium  plays  an  important  role.  Large  masses  of  syncy- 
tium  and  chorionic  epithelium  invade  the  decidua  and  the 
uterine  walls  just  as  in  chorio-epithelioma,  the  process  resembling 
this  disease  which  follows  hydatidiform  mole  in  about  half  the 
cases.  The  translucent  vesicles  are  similar  in  shape  to  the  elements 


442 


HYDATIDIFORM   MOLE 


of  tlio  chorion  of  the  first  two  months,  being  fusiform,  pyriform, 
or  rounded,  they  contain  a  fluid  that  is  similar  to  liquor  amnii,  and 
of  the  chorion  of  the  first  two  months,  being  fusiform,  pyriform, 
they  range  in  size  from  a  pin's  head  to  a  large  grape.  The  mass  of 
vesicles  may  grow  to  the  size  of  a  man's  head,  the  myxomatous 
degeneration  involving  the  entire  surface  of  the  chorion,  or  it  may 


FIG.   1S2. — Ilydatidiform  Mole.     (Bumm.) 

be  a  small  tumor  involving  only  the  placental  portion  of  the  chorion. 
The  mass  is  expelled  by  the  uterus  as  a  rule  in  the  fourth  or  fifth 
month  with  labor  pains  and  hemorrhage,  but  portions  of  the  cystic 
mass  are  apt  to  be  closely  adherent  to  the  uterine  wall  so  that 
some  is  apt  to  be  left  behind,  necessitating  a  curetting.  The  fetus 
may  be  destroyed  in  cases  of  extensive  disease,  or  it  may  be  pre- 


DIAGNOSIS  443 

served  in  cases  of  minor  involvement.    It  is  generally  killed  early. 
Sometimes,  when  the  uterine  blood-vessels  are  eroded,  the  hemor-  • 
rhage  from  hydatidiform  mole  may  be  excessive. 

Symptoms. — In  the  first  few  weeks  of  pregnancy  there  is  no 
means  of  distinguishing  cystic  disease  of  the  chorion.  As  the 
pregnancy  advances  the  uterus  containing  hydatidiform  mole 
increases  in  size  more  rapidly  than  in  the  case  of  normal  pregnancy, 
and  hemorrhage  occurs  with  a  bloody,  watery  discharge,  which  is 
not  unlike  currant- juice  in  appearance. 

Diagnosis. — The  diagnosis  rests  on  the  symptoms  and  on  a 
doughy  feeling  of  the  uterus  on  bimanual  palpation,  this  being 
demonstrable  after  the  third  month  when  the  rapid  growth  of  the 
uterus  becomes  apparent.  If  the  cysts  are  found  in  the  vaginal 
discharge  the  diagnosis  is  certain.  No  fetal  movements  or  heart 
sounds  are  heard  and  there  is  no  ballottement. 

The  possibility  of  the  development  of  chorio-epithelioma  follow- 
ing hydatidiform  mole  should  never  be  lost  sight  of,  and  every 
patient  should  be  kept  under  close  observation  for  at  least  a  month 
after  the  expulsion  of  the  mole. 


CHAPTER  XXIII 
THE  DIAGNOSIS  OF  DISEASES  OF  THE  URETHRA 

Anomalies,  p.  444:  Persistent  urogenital  sinus,  p.  444.  Hypospadias, 
p.  444.  Partial  defect  of  the  external  urethra,  p.  444.  Epispadias,  p.  445. 
Atresia  of  the  urethra,  p.  445. 

Displacements  of  the  urethra  and  alterations  in  form,  p.  445:  Upward 
dislocation,  p.  445.  Downward  dislocation,  p.  446:  Diagnosis,  p.  446; 
Differential  diagnosis,  p.  447,  Urethrocele,  p.  447.  Suburethral  abscess, 
p.  447,  Dilatation  of  the  urethra,  p.  447,  Dangers  attending  dilatation,  p. 
447,  Prolapse  of  the  urethral  mucosa,  p.  448. 

Inflammation  of  the  Urethra,  Urethritis,  p.  450:  Acute  urethritis,  p.  450. 
Chronic  urethritis;  (a)  Diffuse;  (b)  Circumscribed,  p.  451:  Latent 
gonorrhea,  p.  452. 

Stricture  of  the  urethra,  p.  451. 

New  growths  of  the  urethra,  p.  453:  Urethral  caruncle,  p.  453.  Polypus 
of  the  urethra,  p.  455.  Primary  Cancer  of  the  urethra,  p.  455.  Sarcoma  of 
the  urethra,  p.  456. 

THE  anatomy  of  the  urethra  and  the  methods  of  examination 
and  the  teclmique  of  endoscopy  will  be  found  in  Chapter  VIII., 
page  100. 

ANOMALIES 

The  congenital  defects  of  the  urethra  are:  absence  of  the 
urethra,  hypospadias,  dilated  short  urethra,  epispadias,  and 
atresia.  The  development  of  the  urethra  and  bladder  is  shown  in 
the  diagrams  from  Schroeder  in  Chapter  XXL,  page  395.  Where 
the  urethra  has  failed  entirely  to  develop  the  bladder  opens  directly 
into  the  vagina,  and  the  case  may  be  regarded  as  a  persistent 
urogenital  sinus.  Several  of  these  cases  have  been  reported  in  the 
literature,  but  more  common  are  the  instances  of  lack  of  develop- 
ment of  the  lower  portion  of  the  urethra.  If  the  part  lacking  is  the 
posterior  urethral  wall  the  case  is  one  of  hypospadias,  and  if  both 
anterior  and  posterior  walls  are  absent  in  the  lower  course  of  the 
urethra  it  is  a  case  of  partial  defect  of  the  external  urethra.  In  cases 
of  absence  of  the  vagina  the  urethra  is  commonly  found  dilated 
and  short,  in  some  cases  being  of  large  enough  caliber  to  admit 

444 


DISPLACEMENTS  OF  THE  URETHRA  445 

the  penis.  Many  authors  have  assumed  that  the  large  size  of  the 
urethra  in  such  patients  is  due  to  forcible  dilatation  during  coitus, 
but  as  the  large  urethra  is  found  in  unmarried  women  who  are 
the  subjects  of  absence  of  the  vagina — in  patients  who  could 
never  have  been  subjected  to  sexual  intercourse — the  condition 
of  the  urethra  must  be  regarded  as  due  to  a  partial  persistence  of 
the  urogenital  sinus.  Intercourse  has  undoubtedly  taken  place 
through  such  a  urethra  in  many  instances,  but  we  must  not  regard 
the  dilatation  by  the  penis  as  the  primary  cause  of  the  large 
caliber. 

Epispadias  is  a  defect  of  the  upper  wall  of  the  urethra  associated 
with  separation  of  the  labia  minora  and  division  of  the  clitoris. 
In  extreme  cases  of  epispadias  there  is  also  exstrophy  of  the  bladder 
together  with  deficiency  of  the  anterior  bladder  wall.  The  con- 
dition is  rare,  as  is  atresia  of  tJie  urethra,  which  is  supposed  to  be 
due  to  inflammatory  affections  late  in  intra-uterine  life  causing 
more  or  less  complete  occlusion  of  the  urethral  canal.  There  must 
be  some  avenue  of  escape  for  the  urine  even  before  birth  or  else 
the  child  has  great  distention  of  the  abdomen  from  overfilled 
bladder,  ureters,  and  kidneys.  Partial  atresia  may  be  relieved 
soon  after  birth  by  passing  a  sound,  as  in  the  case  reported  by 
Mandl  and  cited  by  Kelly,  in  which  a  child  two  days  old  had  vom- 
iting and  convulsions  until  the  atresia  of  the  urethra  was  broken 
clown  by  a  sound. 

DISPLACEMENTS  OF   THE  URETHRA  AND  ALTERATIONS 

IN  FORM 

UPWAKD  DISLOCATION  OF  THE  URETHRA 

Upward  dislocation  of  the  urethra  may  occur  from  dragging  on 
the  bladder  and  the  urethra  in  the  case  of  large  tumors  and  in 
pregnancy.  It  is  supposed  that  the  traction  on  the  neck  of  the 
bladder  may  be  the  cause  of  frequency  of  urination,  which  some- 
times occurs  in  these  cases;  more  often  there  are  no  symptoms 
at  all.  Rarely  there  is  retention  of  urine,  and  the  catheter, 
when  passed,  traverses  a  long  route  up  behind  the  pubic  bone. 
A  soft  rubber  catheter  is  safer  than  a  glass  or  silver  one  in  such 
cases. 


446  DISEASES  OF  THE  URETHRA 

DOWNWARD  DISLOCATION  OF  THE  URETHRA 

Downward  dislocation  of  the  urethra  is  a  fairly  common  lesion 
resulting  from  child-birth.  The  entire  urethra  may  be  torn  from 
its  pubic  supports,  as  in  the  case  of  procidentia,  or  only  the  upper 
portion  may  be  freed  from  its  fastenings.  Not  infrequently 
careful  examination  will  reveal  dislocation  of  the  upper  third  of 
the  urethra  in  cases  where  prolapse  of  the  uterus  is  not  present. 
We  must  suppose  that  in  these  cases  the  uterus  and  its  ligaments 
have  involuted  and  regained  a  normal  state,  while  the  sundered 
tissues  under  the  pubic  arch  are  unable  to  support  the  urethra 
in  a  normal  situation.  Downward  dislocation  of  the  urethra 
may  be  attended  by  no  symptoms,  or  the  patient  may  experience 
sudden  stoppage  of  the  urine  during  urination,  or  there  may  be 
partial  incontinence.  The  tone  of  a  dislocated  urethra  is  apt  to 
be  below  par,  therefore  such  a  urethra  is  more  likely  to  become  in- 
fected than  is  a  normal  one. 

Diagnosis. — The  diagnosis  is  established  by  palpation  of  the 
urethra  with  a  sound  in  its  canal  and  a  finger  in  the  vagina,  also 
by  inspection  of  the  vagina  while  the  sound  passes  through  the 
urethra,  the  patient  being  in  the  dorsal  position.  For  this  purpose 
employ  a  sound  that  is  about  three-sixteenths  of  an  inch  in  diam- 
eter or  a  Kelly  urethral  dilator  of  the  same  caliber  (4  millimeters) 
so  that  this  larger  sound  may  occupy  the  entire  lumen  of  the 
urethra,  and  thus  indicate  the  true  course  of  the  organ,  and  not 
— as  would  be  the  case  with  a  small  sound — enter  a  diverticulum, 
if  present.  With  this  sound  passed  so  that  its  tip  is  just  below  the 
neck  of  the  bladder,  tilt  the  point  downward  and  note  whether  the 
urethra  is  held  to  the  os  pubis  or  goes  downward  into  the  vagina. 
Next  substitute  a  uterine  sound  for  the  dilator,  bend  the  terminal 
inch  of  the  sound  to  an  angle  of  thirty  degrees,  and  introduce  it  with 
the  point  downward.  If  the  upper  third  of  the  urethra  is  dislocated 
downward  the  point  of  the  sound,  following  the  course  of  the 
displaced  urethra,  may  be  seen  and  felt  in  the  vagina. 

In  my  private  case  records  are  the  notes  of  fifteen  cases  of  clown- 
ward  dislocation  of  the  urethra  not  associated  with  uterine  prolapse. 
In  cases  of  uterine  prolapse  with  accompanying  dislocation  of 
bladder  and  urethra,  the  course  of  the  urethra  in  the  prolapsed 
mass  is  mapped  out  with  the  bent  sound  in  the  urethra. 


DISPLACEMENTS  OF  THE  URETHRA  447 

Differential  Diagnosis. — We  must  differentiate  urethrocele,  which 
is  a  pocket  in  the  lower  wall  of  the  urethra — generally  in  the 
middle  third  of  its  course — from  downward  dislocation  of  the 
urethra.  This  is  done  by  noting  the  general  course  of  the  urethra 
by  means  of  a  large  sound  or  Kelly  dilator  passed  to  the  neck  of 
the  bladder.  Withdraw  the  sound  and  pass  a  bent  probe  through 
the  opening  in  the  urethral  wall  into  the  urethrocele,  following  the 
point  of  the  probe  with  a  finger  in  the  vagina.  Next  pass  a  cysto- 
scope  into  the  urethra  and  see  the  opening  into  the  urethrocele, 
passing  a  probe  through  the  cystoscope  into  the  urethrocele  to 
verify  the  diagnosis.  Urine  may  collect  in  a  urethrocele,  decom- 
pose, and  set  up  a  urethritis.  The  urine  is  ejected  during  the  act 
of  coughing,  laughing,  or  straining,  and  the  patient  complains  of 
this  sort  of  incontinence. 

Dislocation  of  the  urethra  downward  must  be  differentiated 
from  suburethral  abscess,  an  abscess  occupying  the  urethro-vaginal 
septum,  varying  in  size  from  a  cherry  to  a  hen's  egg.  Such  an 
abscess  has  a  chronic  course  and  is  supposed  to  originate  in  Skene's 
glands,  in  a  diverticulum  from  the  urethral  canal,  or  in  a  suppurat- 
ing cyst  of  the  urethro-vaginal  septum.  It  is  the  seat  of  pain  and 
soreness  during  urination,  defecation,  and  coitus,  the  latter  often 
being  impossible  of  accomplishment  because  of  the  tenderness  of 
the  vagina.  The  abscess  generally  opens  into  the  urethra  by  a 
minute  opening,  and  pressure  on  it  through  the  vaginal  wall  causes 
the  sac  to  collapse  as  it  is  emptied.  In  some  cases  the  patient 
experiences  periodic  discharges  of  pus  from  the  urethra.  If  the 
cystoscope  is  passed  up  to  the  vesical  neck  and  withdrawn,  a  few 
drops  of  pus  will  be  seen  to  gush  into  its  lumen  after  the  tip  of  the 
cystoscope  has  passed  the  opening  into  the  abscess.  A  probe 
passed  into  the  opening  and  palpated  per  vaginam  establishes 
the  diagnosis. 

Dilatation  of  the  Urethra. — Congenital  enlargement  of  the  urethra 
has  been  referred  to  in  discussing  the  anomalies  as  a  manifestation 
of  the  persistence  of  a  urogenital  sinus.  Stricture  or  tumor  of 
the  urethra  if  situated  near  the  meat  us  may  cause  dilatation  of  the 
urethra  behind  the  stricture  or  tumor. 

All  of  the  structures  of  the  urethra  are  hypertrophied  during 
pregnancy  and  Skene  thought  that  the  urethra  was  dilated  at 
that  time.  Artificial  dilatation  has  been  caused  by  coitus  per 


448  DISEASES  OF  THE  URETHRA 

urethram  and  by  introducing  foreign  bodies  into  the  urethra  for 
purposes  of  masturbation,  and,  also,  dilatation  of  the  urethra  was 
formerly  practiced  by  physicians  for  the  purpose  of  digital  ex- 
ploration of  the  bladder  for  suspected  stone  or  tumors  of  that  organ. 
The  urethra  is  extremely  tolerant  of  dilatation  and  bladder  stones 
as  large  as  an  inch  hi  diameter  have  been  passed  spontaneously 
through  the  urethra,  followed  by  only  temporary  incontinence. 
Nevertheless,  forcible  dilatation  of  the  urethra  to  a  diameter  of 
more  than  half  an  inch  (12  millimeters)  is  entirely  unjustifiable, 
because  permanent  incontinence  is  very  apt  to  be  the  result.  Few 
physicians  possess  a  forefinger  whose  knuckle  at  the  end  of  the 
first  phalanx  measures  less  than  three-  quarters  of  an  inch  (18 
millimeters)  in  diameter  and  most  forefingers  are  much  larger. 
The  interior  of  the  bladder  can  not  be  palpated  unless  this  knuckle 
is  passed  into  the  urethra.  Examination  with  the  little  ringer  is 
inadequate,  although  the  lower  portions  of  the  bladder  may  be 
reached  with  its  tip.  Modern  methods  of  cystoscopy  do  away 
with  the  need  of  digital  exploration  and  we  may  subscribe  to  Dr. 
Thomas  Addis  Emmet's  vigorous  statement  to  his  students  hi  the 
old  days  at  the  Woman's  Hospital,  that  the  man  who  dilates  a 
woman's  urethra  with  his  finger  should  be  put  in  jail. 

The  diagnosis  of  a  dilated  urethra  is  made  by  observing  pouting 
of  the  meatus,  and  a  distinct  ridge  in  the  vagina  corresponding 
to  the  course  of  the  urethra.  By  touch  per  vaginam  the  enlarged 
urethra  may  be  felt  as  an  elastic,  rolled-up,  membranous  tube, 
and  on  introducing  a  large  Kelly  dilator  into  the  urethra,  it  slips 
easily  into  the  bladder.  Moving  the  tip  of  a  uterine  sound  about 
in  the  urethra  we  determine  an  enlarged  canal,  and  by  palpating 
the  sound  per  vaginam  we  learn  the  thickness  of  the  tissues  of  the 
urethro-vaginal  septum.  The  No.  12  cystoscope  passes  easily, 
and  the  larger  sizes  of  the  urethral  dilators  introduced  successively 
will  tell  of  the  exact  diameter  of  the  urethra. 

Prolapse  of  the  Urethral  Mucosa. — This  rare  affection  consists 
of  an  eversion  or  turning  out  of  the  urethral  mucous  membrane 
through  the  meatus.  For  some  reason  the  hypertrophied  mucosa 
becomes  loosened  from  its  attachments  and  is  extruded  from  the 
external  orifice  in  the  shape  of  a  deep  red  or  bluish  tumor  with 
the  orifice  of  the  urethra  in  its  center.  The  extreme  grade  of  this 
affection  is  most  often  found  in  debilitated  old  women  and  in 


DISPLACEMENTS  OF  THE  URETHRA 


449 


young  children;  a  moderate  amount  of  eversion  may  occur  in  any 
woman  who  has  had  children.  In  the  pronounced  grades  the 
prolapsed  mucous  membrane  may  become  edematous  or  even 
gangrenous.  The  diagnosis  is  made  by  discovering  a  deep  red 
tumor  in  the  situation  of  the  vestibule,  that  is  covered  everywhere 
with  easily  bleeding  mucous  membrane,  and  has  a  slit  in  its 
center  that  gives  access  to  the  bladder.  If  only  a  portion  of 


FIG.  183. — Prolapse  of  the  Urethral  Mucous    Membrane.    (Montgomery.) 

the  circumference  of  the  urethra  is  involved  in  the  prolapse  the 
everted  mucosa  may  be  mistaken  for  a  polypus,  a  urethral  caruncle, 
or  eversion  of  the  bladder  mucosa.  If  the  prolapsed  mucous  mem- 
brane is  seized  with  a  delicate  pair  of  forceps  and  drawn  down  it 
will  be  found  to  have  a  broad  l>ase  and  will  be  increased  in  size; 
in  the  case  of  a  polypus  or  caruncle  drawing  the  tumor  down  will 

show  a  pedicle,  and  no  increase  in  size  beyond  the  elongation  due 
29 


450  DISEASES  OF  THE  URETHRA 

to  traction.     In  many  cases  the  everted  mucosa  may  be  replaced 
in  the  urethra  by  the  use  of  cocaine  and  taxis. 

If  the  case  is  one  of  e version  of  the  mucosa  of  the  bladder,  the 
sound  passed  into  the  urethra  can  be  made  to  sweep  entirely  around 
the  tumor,  and  when  passed  further  there  is  no  bladder  cavity  to 
receive  it.  By  taxis  and  pressure  with  a  large-sized  sound  the 
prolapsed  mucous  membrane  may  be  pushed  into  the  bladder. 
Cystoscopy  will  show  the  distended  bladder  and  the  portion  of 
the  lining  that  had  been  prolapsed  to  be  of  a  deep  red  color. 


INFLAMMATION  OF  THE  URETHRA:  URETHRITIS 

Urethritis  is  a  common  affection  in  women,  though  not  so  often 
diagnosed  as  in  the  male;  "irritable  bladder"  and  "cystitis,"  in 
the  place  of  an  exact  diagnosis,  often  meaning  urethritis.  With 
the  more  general  use  of  the  endoscope  we  are  learning  more  of 
this  disease.  It  is  most  often  due  to  the  gonococcus,  but  may  be 
due  to  an  extension  downward  of  a  cystitis,  to  traumatism — as 
from  injuries  during  childbirth  or  from  the  passage  of  a  calculus — 
to  urethral  new  growths,  or  to  an  extension  upward  of  a  vulvitis. 
The  disease  is  limited  to  the  mucous  and  submucous  tissues,  which 
are  injected,  swollen,  and  secrete  pus;  the  upper  and  lower  portions 
of  the  urethra  being  more  often  affected  than  the  middle  part. 
Urethritis  occurs  in  two  forms,  acute  urethritis,  and  chronic  ure- 
thritis, the  inflammatory  process  having  a  marked  tendency  to 
lurk  in  Skenc's  glands.  This  is  true  especially  of  the  gonococcus 
form,  which  may  be  cured  apparently,  only  to  be  lighted  up  anew 
into  an  acute  attack  when  the  gonococci  have  found  fresh  culture 
material  in  another  individual. 

Acute  Urethritis. — Acute  urethritis  begins  with  burning  and 
itching  in  the  neighborhood  of  the  urethra,  followed  in  one  or  two 
days  by  painful  micturition.  The  body  temperature  may  be 
elevated  and  anorexia  and  lack  of  energy  may  be  present  for  a 
short  time.  The  patient  notices  that  her  linen  is  discolored  by  a 
purulent  discharge  and  even  by  blood;  for  there  may  be  bleeding 
in  the  most  acute  stage.  The  local  examination  should  be  made 
before  the  patient  has  urinated.  The  dorsal  position  is  used.  A 
drop  of  pus  appears  in  the  meatus  and  the  mucosa  at  the  orifice 


URETHRITIS  f-  f  I?  F  /:  p  ",45ft  p 

of  the  urethra  is  injected,  red,  and  swollen!  "Stroking  the  urtethr*-^ 
from  above  downward  by  a  finger  in  the  vagina,  pu.-i  issues  from  1 
the  orifice  of  the  urethra.  If  it  does  not  come  from  the  urethra 
it  may  be  expressed  from  the  openings  of  the  canals  of  Skene's 
glands,  which  are  situated  one  on  each  side  hi  the  lower  portion 
of  the  labia  urethrae  just  inside  the  meatus.  The  finger  in  the 
vagina  notes  increased  body  heat  and  tenderness  of  the  urethra. 
In  this  acute  stage  it  is  just  as  well  not  to  use  the  endoscope  be- 
cause of  the  damage  it  must  inflict  on  the  inflamed  mucosa.  If  it 
is  used  with  the  aid  of  a  strong  solution  of  cocaine,  the  mucous 
membrane  is  seen  to  be  bright  red  and  bleeding  easily  and  pus 
issues  from  between  the  folds  and  from  the  minute  glands,  or  there 
are  to  be  seen  linear  ulcers  two  to  four  millimeters  long  and  one 
millimeter  broad,  generally  on  the  posterior  wall.  Great  care 
should  be  exercised  not  to  introduce  the  endoscope  (Kelly  Cysto- 
scope  No.  8)  beyond  the  bladder  neck,  for  fear  of  infecting  the 
bladder.  Smears  should  be  made  and  examined  for  the  gonococcus. 
Concomitant  inflammation  of  one  or  both  of  Bartholin's  glands 
indicates  probable  gonococcus  infection. 

Chronic  Urethritis. — Chronic  urethritis  is  the  form  of  urethral 
inflammation  most  often  seen  by  the  gynecologist.  It  commonly 
follows  acute  urethritis,  although  the  latter  may  have  given  very 
few  symptoms  and  may  not  have  been  diagnosed. 

The  disease  is  diffuse  or  circumscribed. 

(a)  Diffuse  Chronic  Urethritis. — This  generally  follows  acute 
urethritis.  The  longer  the  inflammatory  process  has  existed  the 
paler  becomes  the  mucosa  and  the  greater  the  thickening  of  the 
mucous  and  submucous  tissues  because  of  new  formation  of  con- 
nective tissue.  In  the  later  stages  of  chronic  urethritis  the  urethra 
is  felt  as  a  hard  tube,  only  moderately  tender  to  touch.  The  symp- 
toms may  be  nothing  more  than  itching  or  burning  in  the  region 
of  the  urethra  and  perhaps  frequency  of  micturition.  There  is  some 
swelling  and  a  gelatinous  and  granular  condition  of  the  mucosa 
at  the  external  orifice.  The  mucosa  pouts  out  into  the  lumen 
of  the  endoscope  so  that  the  canal  appears  closed;  it  is  dull  red  in 
color,  granular  and  soft,  and  the  lacuna4,  crypts,  and  openings  of 
the  glands  show  as  deeper  red  spots,  perhaps  giving  exit  to  pus. 
The  disease  is  most  often  met  with  in  prostitutes. 

(6)  Circumscribed  Chronic    Urethritis. — In   this   form   one   sees 


452  DISEASES  OF  THE  URETHRA 

through  the  cystoscope  patches  of  pale,  almost  gray  mucous  mem- 
brane surrounded  by  the  pale  red,  normal  mucosa.  Later  the 
pale  areas  become  whiter  still  as  they  represent  scar  tissue,  and 
they  sometimes  form  strictures  of  the  urethra.  When  the  specu- 
lum is  passed  through  such  cicatricial  areas  they  show  decreased 
elasticity  and  tear  easily,  causing  bleeding.  The  chronic  inflam- 
mation may  be  limited  to  the  region  of  Skene's  glands.  In  this 
case  there  will  be  reddening  about  the  orifices  of  the  ducts  of  the 
glands  and  pressure  through  the  vagina  will  express  a  drop  of  pus 
or  turbid  serum  from  the  gland.  The  discharge  is  apt  to  be  thin 
and  serous  in  the  chronic  cases,  and  gonococci  are  few.  Careful 
search  for  this  organism  should  be  made.  Skene's  glands  are 
among  the  chief  lurking  places  of  latent  gonorrhea,  the  other  most 
frequent  situations  being  the  cervical  canal  and  Bartholin's  glands. 
If  the  gonococcus  can  be  isolated  from  the  discharge  from  either 
of  the  latter  organs,  even  though  it  is  absent  in  the  urethral  dis- 
charge, the  inference  is  that  gonococcus  infection  of  the  urethra 
is  present  also.  Several  microscopic  examinations  should  be  made 
from  the  discharges  from  each  of  the  three  situations  before  pro- 
nouncing that  gonorrhea  is  absent. 


STRICTURE   OF   THE  URETHRA 

Van  dc  Warkcr  as  long  ago  as  1887  called  attention  to  the  fre- 
quency and  importance  of  strictures  of  large  caliber  in  women.  My 
own  experience  has  taught  me  that  such  strictures  are  relatively 
frequent  and  arc  found  by  the  physician  who  does  a  good  deal  of 
cystoscopic  work.  In  my  private  records  are  the  notes  of  nine  cases 
that  I  have  seen,  and  Pasteau  (quoted  by  Knorr)  saw  twelve  cases 
and  had  collected  one  hundred  and  twelve  from  the  literature. 

Strictures  are  caused  by  chronic  gonorrheal  urethritis,  by  in- 
juries of  the  urethra  during  labor,  by  cicatricial  contracture  of  the 
anterior  vaginal  wall,  due  to  a  slough,  or  very  rarely  to  cicatriza- 
tion of  a  chancre,  or  carcinoma  of  the  urethra.  Stricture  at  the 
meatus  sometimes  results  from  kraurosis  vulvir. 

The  symptoms  of  stricture  arc:  painful  and  difficult  micturition, 
the  urine  being  passed  in  a  small  stream.  A  small  mcatus  is  very 
commonly  met  with  in  women  and  is  diagnosed  by  passing  the 


NEW  GROWTHS  OF  THE  URETHRA  453 

conical  calibrator.  Any  measurement  in  the  adult  under  6  milli- 
meters must  be  classed  as  small.  A  stricture  is  detected  by  passing 
the  graduated  urethral  dilators  and  noting  the  situation  and  size 
of  the  point  of  resistance.  Through  the  cystoscope  one  sees  irreg- 
ular rolling-in  of  the  mucosa  and  asymmetry,  the  strictured  portion 
being  whiter  than  the  surrounding  mucosa,  non-elastic,  and  bleeding 
if  stretched. 


NEW  GROWTHS  OF  THE  URETHRA 

The  new  growths  observed  as  occurring  in  the  urethra  are  car- 
uncle, polypi,  cancer,  and  sarcoma. 

Urethral  Caruncle. — Urethral  caruncle  is  the  term  used  to  denote 
a  highly  vascular  tumor  which  projects  from  the  urinary  meatus. 
It  is  a  common  affection.  Lange  has  described  three  forms  ac- 
cording to  their  pathology;  (a)  granuloma,  (6)  papillary  angioma, 
and  (c)  telangiectatic  non-papillary  mucous  polyp. 

a.  The  granuloma  is  characterized  by  infiltration  of  round  cells 
and  abundant  capillaries,  and  is  the  result  of  a  gonorrheal  lesion  of 
the  urethra,  b.  Papillary  angioma  is  a  highly  vascular  mucous 
polyp.  It  has  a  covering  of  pavement  epithelium  with  nipple-like 
elevations,  and  is  invaded  by  connective-tissue  elements,  c.  The 
telangiectatic  variety  is  characterized  by  an  abundance  of  thin- 
walled  capillaries,  these  being  so  dilated  often  as  to  give  the  tissue 
a  cavernous  character;  they  may  even  contain  cysts.  This  tumor 
has  no  papillae. 

All  three  varieties  are  found  with  equal  frequency  in  middle  life, 
the  granuloma  is  more  often  found  in  young  women  between  twenty 
and  forty,  and  the  papilloma  variety  in  women  over  forty.  As  a 
rule,  urethral  caruncle  is  observed  late  in  the  childbearing  period 
of  life,  although  it  may  be  found  at  any  age  from  childhood  to  old 
age.  The  symptoms  are  excessive  pain  on  urination  and  sensitive- 
ness of  the  vulva,  even  to  the  slightest  touch,  also  frequency  of 
micturition  and  derangement  of  the  nervous  system.  Patients 
may  hold  their  urine  for  long  periods  of  time  to  avoid  the  pain 
experienced  on  passing  it.  Pains,  which  we  may  call  sympathetic, 
radiate  in  all  directions  from  the  pelvis,  just  as  in  vaginismus. 
One  of  my  patients  complained  of  a  spasmodic  drawing  up  of  one 


DISEASES  OF  THE  URETHRA 


thigh  so  that  when  she  walked  one  leg  seemed  shorter  than  the 
other.  Physical  examination  showed  no  difference  in  the  length 
of  the  limbs  and  no  abnormality  in  the  locomotor  apparatus. 
The  symptom  was  entirely  clone  away  with  by  the  removal  of  the 
caruncle.  Coitus  is  painful  or  impossible.  The  patient  with  a 
caruncle  is  apt  to  be  morose,  depressed,  anxious,  or  even  hysterical. 
The  diagnosis  is  established  by  the  appearances.  On  separating 


FIG.  184. — Urethral  Caruncle.     (Montgomery.) 

the  labia  one  sees  a  brilliant  red  growth  projecting  from  the  meatus. 
It  may  look  like  a  cock's  comb  or  a  very  small  raspberry  and  varies 
in  size  from  a  BB  shot  to  a  cherry, — large  ones  being  unusual. 
Its  surface  is  generally  smooth,  but  may  be  roughened  like  the 
surface  of  a  raspberry.  The  growth  generally  springs  from  the 
posterior  wall  of  the  urethra  just  inside  the  meatus  and  is  either 
pedunculated  or  sessile.  With  a  few  exceptions  urethral  caruncle 


NEW  GROWTHS  OF  THE  URETHRA  455 

is  exquisitely  sensitive;  now  and  then  a  non-sensitive  tumor  is 
seen.  It  bleeds  easily,  but  does  not,  as  a  rule,  bleed  enough  to 
soil  the  patient's  linen,  but  a  purulent  vaginal  discharge  is  a  common 
accompaniment  of  these  growths,  perhaps  because  they  are  fre- 
quently of  gonorrheal  origin.  They  are  of  slow  growth  and  almost 
always  recur  when  removed  unless  every  bit  of  tumor  tissue  has 
been  taken  out;  but  the  recurrent  growth  is  like  the  first,  and  there 
is  no  tendency  to  malignancy  or  to  extension  beyond  the  original 
site.  A  thorough  diagnosis  can  not  be  made  often  without  cocaine 
or  an  anesthetic.  The  meatus  must  be  dilated  with  the  conical  cali- 
brator and  the  exact  situation  and  extent  of  the  base  of  the  tumor 
determined  by  the  aid  of  the  cystoscope. 

Polypus  of  the  Urethra. — Certain  forms  of  caruncle  are  polypi, 
as  already  stated  in  the  consideration  of  caruncle.  Mucous  polypi 
situated  in  the  middle  and  upper  urethra  are  very  rare.  They 
cause  few  symptoms  and  are  to  be  seen  through  the  endoscope. 
A  few  cases  of  fibroma  of  the  urethra  have  been  described  and 
one  or  two  cases  of  myoma. 

Primary  Cancer  of  the  Urethra. — This  is  a  rare  disease,  there  being 
on  record  in  1903  only  nine  authentic  cases.  Secondary  cancer 
of  the  urethra,  on  the  other  hand,  is  not  so  uncommon.  The 
primary  disease  is  a  disease  of  older  women  and  seems  to  start  in 
the  tissues  about  the  lower  urethra  more  often  than  in  the  urethra 
itself  and  to  invade  the  mucous  membrane  late.  Strictly  speaking, 
only  the  form  of  cancer  beginning  in  the  urethral  tissues  should 
be  classed  as  cancer  of  the  urethra,  but  after  the  mucous  membrane 
has  been  destroyed  the  differentiation  of  the  primary  point  of 
origin  is  necessarily  difficult.  The  disease  must  be  differentiated 
from  caruncle,  chancre,  and  tuberculosis.  In  caruncle  the  tumor 
is  soft  and  does  not  increase  in  size;  it  is  situated  in  the  urethral 
canal,  generally  on  the  posterior  wall.  In  the  case  of  primary  cancer 
the  growth  is  hard  and  is  seldom  seen  before  it  has  involved  a 
wide  area.  The  ulcer  of  a  chancre  follows  a  suspicious  intercourse 
with  a  definite  period  of  incubation,  twenty-six  days.  It  heals  in 
a  short  time,  leaving  a  scar.  The  ulceration  of  cancer  is  of  long 
duration,  it  extends  to  the  surrounding  parts,  and  the  history  of 
infection  is  absent.  Perhaps  the  Spirochseta  pallida  can  be  isolated 
from  the  discharge.  In  the  case  of  a  tuberculous  ulcer  the  cheesy 
matter  and  the  tubercles,  characteristic  of  tuberculosis,  may  be 


456  DISEASES  OF  THE  URETHRA 

seen  by  the  naked  eye,  and  there  is  little  or  no  induration  of  the 
base  of  the  ulcer  as  in  the  case  of  both  cancer  and  chancre.  In  all 
doubtful  cases  a  piece  of  tissue  should  be  excised  for  microscopic 
examination. 

Sarcoma  of  the  Urethra. — This  is  a  very  rare  disease,  only  four 
cases  having  been  reported.  Three  of  the  cases  were  in  women 
fifty  years  of  age  or  older,  and  the  fourth  in  a  child  of  three.  The 
symptoms  are  bleeding  and  the  presence  of  a  tumor  in  the  situation 
of  the  urethra.  The  tumor  is  to  be  removed  and  examined  under 
the  microscope. 


CHAPTER  XXIV 
THE  DIAGNOSIS  OF  DISEASES  OF  THE  BLADDER 

Anomalies,  p.  457:  Absence  of  the  bladder,  p.  457.  Double  bladder,  p. 
458.  Loculate  bladder,  p.  458.  Epispadias  and  exstrophy  of  the  bladder, 
p.  459. 

Alterations  in  form,  and  displacements,  p.  459:  Distended  bladder,  p.  459. 
Rupture  of  the  bladder,  p.  460.  Contraction  of  the  bladder,  p.  461.  Up- 
ward displacement,  p.  461.  Downward  displacement,  p.  461.  Lateral 
displacement,  p.  462.  Hernia  of  the  bladder,  p.  462.  Eversion  of  the 
bladder,  p.  462. 

Foreign  Bodies  in  the  bladder,  p.  462 :  Calculi,  p.  462.  Other  foreign 
bodies,  p.  463. 

Cystitis,  p.  465:  Classification,  p.  466:  Etiology  and  pathology,  p.  466: 
Catarrhal  cystitis,  p.  467;  Ulcerative  cystitis,  p.  468;  Exfoliative  cystitis, 
p.  468;  Tuberculous  cystitis,  p.  468.  Certain  rare  forms  of  cystitis,  p.  470. 
Symptoms  of  cystitis,  p.  471.  Diagnosis  of  cystitis,  p.  471. 

Varix  of  the  bladder,  p.  474. 

Fistulse  of  the  bladder,  p.  474:  (1)  Vesico-vaginal  fistula,  p.  474;  Fre- 
quency, etiology  and  pathology,  p.  474;  Symptoms,  p.  476;  Diagnosis,  p. 
477:  Differential  Diagnosis,  p.  478.  (2)  Vesico-uterine  fistula, p.  479;  Vesico- 
utero-vaginal  fistula,  p.  479.  (3)  Vesico-intestinal  and  other  fistulae,  p.  479. 

New  Growths  of  the  bladder,  p.  480:  Symptoms,  p.  481.  Diagnosis,  p. 
481.  Benign  tumors,  p.  482;  Papilloma,  p.  482;  Fibroma  and  Myoma, 
p.  483;  Adenoma,  p.  483.  Malignant  tumors,  p.  483 :  Carcinoma,  p.  483; 
Sarcoma,  p.  484. 

Functional  Disturbances  of  the  bladder,  p.  485. 

THE  anatomy  and  technique  of  examination  of  the  bladder 
have  been  described  in  Chapter  VIII.,  page  107. 

The  diagnosis  of  diseases  of  the  bladder  is  made  by  study  of  the 
history,  by  analysis  of  the  urine,  and  by  direct  examination  of  the 
organ  by  means  of  palpation  of  its  exterior  and  by  inspection  of 
its  illuminated  interior. 

ANOMALIES 

Absence  of  the  bladder  is  a  very  rare  malformation  and  is  generally 
associated  with  a  non-viable  child.  In  these  cases  the  ureters 
terminate  in  the  urethra,  the  rectum,  or  the  vagina. 

457 


458  DISEASES  OF  THE  BLADDER 

Double  bladder  is  another  very  rare  malformation,  which  is  apt 
to  be  associated  with  duplication  of  the  other  pelvic  organs,  as  in 
a  case  reported  by  Suppingcr,  in  which  there  was  a  double  bladder 
and  also  double  urethra,  clitoris,  hymen,  and  anus,  each  half  of 
the  pelvis  containing  a  uterus  unicornis,  an  ovary,  and  a  tube. 

Loculate  bladder,  or  a  bladder  presenting  congenital  pockets  or 
diverticula  which  project  outward  from  the  main  cavity  of  the 
bladder,  is  not  so  rare,  and  the  same  may  be  said  of  a  bladder 
partially  divided  by  a  median  septum.  The  congenital  loculate 
bladder  is  not  to  be  confused  with  the  bladder  pocketed  by  calculi 
or  by  inflammatory  disease,  neither  is  it  to  be  classed  as  an  instance 


FIG.  185. — The  Base  of  the  Bladder  showing  Diverticula.     (Knorr.) 

of  supernumerary  bladders  or  double  bladder,  already  mentioned. 
The  diagnosis  is  established  by  observing  the  loculi  through  the 
cystoscope  and  noting  that  they  are  separated  by  ridges  of  mucous 
membrane,  and  not  by  scar  tissue,  the  latter  being  hard  and  white, 
and  the  former  soft  and  pink. 

A.  L.  Chute  (Boston  J\[edical  and  Surgical  Journal,  March  22, 
1906,  p.  309)  has  called  attention  to  a  case  in  which  a  diverticulum 
of  the  bladder  existed  as  the  result  of  a  previous  suprapubic 
cystotomy,  the  pocket  acting  as  a  storehouse  for  organisms  that 
had  periodically  reinfected  the  bladder.  In  the  same  paper  he 
mentions  a  congenital  diverticulum,  diagnosed  by  the  cystoscope, 
that  acted  apparently  in  the  same  way. 


ANOMALIES   AND   DISPLACEMENTS  459 

Hypospadias,  a  condition  of  persistent  urogenital  sinus,  has 
been  referred  to  under  diseases  of  the  urethra. 

Epispadias  and  exstrophy  of  the  bladder  are  rarer  in  the  female 
than  in  the  male  and  are  very  seldom  met.  There  is  a  failure  of 
development  in  early  fetal  life  both  of  the  anterior  wall  of  the 
bladder  and  of  the  anterior  abdominal  wall  over  the  bladder,  and 
if  the  entire  front  wall  of  the  bladder  is  wanting,  the  symphysis 
pubis  is  absent  also.  The  posterior  wall  of  the  bladder  appears  as 
a  bleeding,  reddened,  rounded  mass  where  the  symphysis  should 
be,  just  above  the  orifice  of  the  vagina,  and  in  its  surface  the 
openings  of  the  ureters  can  be  seen  spurting  urine  from  time  to  time. 
The  surface  of  the  everted  bladder  wall  is  covered  with  mucus 
and  urine,  and  the  odor  of  decomposed  urine  is  strong.  The  urethra 
is  generally  wanting  in  these  cases,  the  clitoris  is  fissured,  and  the 
vagina  and  uterus  are  apt  to  be  undeveloped,  although  several 
cases  of  pregnancy  occurring  in  the  subjects  of  exstrophy  of  the 
bladder  have  been  reported.  Many  of  these  malformed  individuals 
die  in  early  childhood.  Excoriations  and  ulcerations  of  the  skin 
surrounding  the  ectropion  are  generally  present  because  of  the 
constant  escape  of  urine,  and  infection  of  the  ureters  and  kidneys 
is  a  common  complication.  The  general  health  is  impaired  on 
account  of  the  local  discomfort,  the  complications,  and  the  inability 
to  perform  the  ordinary  duties  of  life. 


ALTERATIONS  IN  FORM,  AND  DISPLACEMENTS 

Distended  Bladder. — The  shape  of  the  distended  bladder  in  the 
woman  is  determined  by  its  surroundings.  The  uterus  and  broad 
ligaments  behind  limit  its  excursion  in  that  direction,  therefore 
its  greatest  diameter  when  moderately  distended  is  not  longi- 
tudinal, as  in  the  male,  but  transverse.  In  extreme  distention 
when  the  vault  rises  into  the  abdomen  the  long  diameter  is  on  a 
line  drawn  from  the  base  of  the  bladder  to  the  umbilicus.  A  dis- 
tended bladder  of  this  sort  resembles  an  ovarian  tumor  rising  from 
the  pelvis.  (See  Fig.  &ia,  page  217.)  Percussion  of  the  anterior 
abdomen  for  a  distance  of  a  hand's  breadth,  more  or  less,  above 
the  symphysis,  elicits  a  flat  note,  and  fluctuation  may  be  deter- 
mined by  bimanual  palpation.  The  catheter  must  be  passed  in 


4GO  DISEASES  OF  THE  BLADDER 

all  doubtful  cases,  and  especially  is  this  precaution  necessary  if 
there  is  a  history  of  dribbling  of  urine.  In  the  case  of  the  overfilled 
bladder  the  desire  to  urinate  ceases  when  the  distention  becomes 
extreme  and  the  repeated  involuntary  loss  of  small  quantities  of 
urine  may  be  the  only  symptom.  If  the  bladder  is  very  much 
distended  the  distress  and  pain  in  the  lower  abdomen  which  ac- 
company the  earlier  stages  of  distention  may  be  absent.  Patients, 
strange  as  it  may  seem,  are  very  apt  not  to  realize  that  the  bladder 
has  not  been  emptied  and  to  give  the  physician  the  impression 
that  they  have  been  passing  their  urine,  only,  perhaps,  too  fre- 
quently. 

Rupture  of  the  bladder  may  occur  either  by  violence  from  with- 
out, as  from  blows  or  falls  when  the  bladder  is  distended,  or 
from  excessive  muscular  efforts  on  the  part  of  the  patient 
herself,  as  in  labor,  or  in  the  struggles  of  anesthesia.  Rupture 
is  more  likely  to  occur  if  the  bladder  wall  has  been  thinned  by 
ulceration  and  sloughing,  as  well  as  by  distention.  It  has  been 
known  to  occur  in  extra-uterine  pregnancy  as  well  as  from  all  sorts 
of  trauma. 

One  of  the  most  frequent  causes  seems  to  be  retroversion  of  the 
pregnant  uterus.  Krukenberg  and  Rivington  collected  between 
them  the  reports  of  twenty  cases  of  this  sort.  Krukenberg  thinks 
that  in  cases  of  retroversion  and  incarceration  of  the  pregnant  ute- 
rus the  physician  should  proceed  with  great  caution  in  replacing  the 
uterus,  and  if  portions  of  gangrenous  bladder  wall  have  been  passed 
per  urethram,  abortion  should  be  performed  rather  than  replace- 
ment, because  of  the  danger  of  rupturing  the  bladder  during  the 
necessary  manipulations.  Rupture  is  commonly  intra-peritoneal 
and  uncommonly  extra-peritoneal.  The  diagnosis  of  rupture  de- 
pends on  sudden  abdominal  pain  and  collapse.  The  sound  passed 
into  the  bladder  goes  an  indefinite  distance  up  into  the  abdominal 
cavity  through  the  rent  in  the  bladder,  while  the  catheter  shows 
that  the  bladder  is  empty.  In  the  event  of  extra-peritoneal 
rupture  the  symptoms  are  less  severe  and  urinary  extravasation 
appears  in  the  course  of  a  few  hours.  In  such  case  the  sound  can 
not  be  passed  such  a  long  distance  as  when  the  opening  is  into  the 
peritoneal  cavity.  Sterile  salt  solution  injected  into  the  bladder 
causes  no  swelling  of  the  viscus  as  determined  by  bimanual  pal- 
pation if  the  rupture  is  intra-peritoneal.  Cystoscopy  is  out  of  the 


DISPLACEMENTS  461 

question  in  these  cases  because  of  the  grave  condition  of  the 
patient.  The  abdomen  should  be  opened  at  once. 

Contraction  of  the  bladder  is  generally  due  to  cystitis,  to  inflamma- 
tory adhesions  about  the  bladder,  or  to  a  habit  of  frequency  of 
micturition.  The  symptom  is  frequency  of  urination.  The  diag- 
nosis is  established  by  injecting  fluid  until  the  patient  has  a  strong 
desire  to  urinate  or  until  the  fluid  is  expelled.  Measure  the  amount 
in  a  glass  graduate.  It  may  be  only  an  ounce  or  two.  By  cystos- 
copy  the  bladder  will  not  dilate  well  when  air  is  admitted  and  the 
mucous  membrane  is  wrinkled  and  corrugated;  scar  tissue  will  be 
seen  if  the  contraction  is  due  to  old  inflammatory  processes  in  the 
bladder. 

Upward  displacement  of  the  bladder  not  associated  with  dis- 
tention  is  met  with  in  the  case  of  large  fibroids  of  the  uterus.  The 
bladder  is  flattened  out  on  the  anterior  face  of  the  tumor  and  its 
fundus  may  even  reach  as  high  as  the  umbilicus.  The  relative 
infrequency  of  urinary  symptoms  in  these  cases  has  always  been  a 
source  of  surprise  to  me.  Palpation  of  the  tumor  will  show,  pro- 
vided the  abdominal  walls  are  lax  and  thin,  an  elastic  swelling  on 
the  anterior  aspect  of  the  tumor.  The  passage  of  the  sound  into 
the  bladder  permits  the  mapping  out  of  its  confines.  This  pro- 
cedure should  never  be  omitted  by  the  surgeon  in  the  diagnosis  of 
large  fibroids,  for  the  operator  should  know  where  the  bladder  is 
situated  before  he  opens  the  abdomen,  rather  than  cut  into  it  by 
mistake  in  the  course  of  an  operation  for  the  removal  of  a  tumor — 
a  not  very  rare  happening. 

Downward  displacement  of  the  bladder  occurs  whenever  the 
anterior  segment  of  the  pelvic  floor  is  displaced  downward.  It  is 
generally  associated  with  uterine  prolapse  and  with  rupture  of  the 
perineum  and  pelvic  floor.  When  the  base  of  the  bladder  projects 
into  the  anterior  wall  of  the  vagina  the  condition  is  known  as 
cystoccle.  The  diagnosis  of  this  condition  is  to  be  found  in  Chapter 
XX.,  page  366  (see  also  Chapter  V.,  The  Mechanics  of  the  Pelvic 
Floor)  page  221.  It  is  rare  for  the  entire  bladder  to  be  in  the  sac  of 
a  complete  uterine  prolapse,  a  portion  of  the  organ  remaining  in  the 
pelvis  in  almost  all  cases.  When  a  part  of  the  bladder  is  prolapsed 
and  a  part  is  behind  the  pubic  bone  the  organ  may  assume  an  hour- 
glass shape.  Exceptionally,  in  the  presence  of  procidentia,  the 
bladder  becomes  detached  from  its  connections  with  the  vagina 


402  DISEASES  OF  THE  BLADDER 

and  remains  in  its  normal  situation.  The  diagnosis  of  the  situation 
of  the  bladder  is  established  by  means  of  the  sound  passed  into  the 
bladder.  (See  Fig.  89,  page  227.)  In  cases  where  the  base  has  been 
displaced  the  ureteral  orifices  are  displaced  also,  although  they 
always  bear  the  same  relation  to  the  internal  orifice  of  the  urethra. 

Lateral  displacement  occurs  when  an  inflammatory  mass  or  tu- 
mor occupies  one  half  of  the  pelvis,  the  bladder  being  obliged  to 
expand  into  the  opposite  half  of  the  pelvis.  Here  the  asymmetry 
may  be  determined  with  a  sound,  measurements  being  taken  of 
the  depth  of  the  bladder  in  various  directions. 

Hernia  of  the  Bladder. — The  bladder  wall  may,  very  rarely,  be 
pushed  into  the  inguinal  and  femoral  canals  and  form  a  part  of  a 
hernia. 

Eversion  of  the  bladder  through  a  dilated  urethra  is  a  rare  form 
of  displacement.  The  entire  thickness  of  the  bladder  wall  is  in- 
volved and  the  protruded  mass  appears  as  a  bright  red  tumor 
projecting  from  the  urethral  orifice.  The  mechanism  of  the  pro- 
duction of  eversion  appears  to  be  as  follows:  Given,  a  large  urethra, 
as  in  the  congenital  enlargement  described  on  page  444,  the  patient 
strains  excessively,  perhaps  because  of  constipation  or  diarrhea, 
and  the  posterior  wall  of  the  bladder  is  forced  into  the  neck  of  the 
bladder  and  then  into  the  urethra,  to  present,  in  the  course  of 
time,  at  the  external  orifice.  In  extreme  instances  the  entire 
bladder  has  been  found  turned  inside  out  through  the  urethra. 
Eversion  is  observed  most  frequently  in  young  children,  and  in  the 
very  old.  The  diagnosis  is  made  by  noting  the  ureteral  orifices  in 
the  prolapsed  mass,  by  passing  a  sound  introduced  in  the  urethra 
round  the  tumor  and  finding  that  it  is  attached  nowhere  to  the 
urethral  wall,  and  by  observing  that  the  sound  will  not  pass  beyond 
the  neck  of  the  bladder.  An  anesthetic  is  necessary  in  order  to 
reduce  the  eversion.  When  the  bladder  wall  has  been  pushed  back, 
the  fact  that  the  urethra  is  dilated  will  be  apparent,  and  the  bladder 
can  be  filled  with  fluid,  and  also  inspected  with  a  cystoscope. 

FOREIGN  BODIES  IN  THE  BLADDER 

Calculi. — The  foreign  body  most  frequently  found  in  the  bladder 
is  a  calculus  or  stone.  This  may  have  reached  the  bladder  from 
the  kidnev  through  the  ureter— in  which  case  the  stone  is  said  to 


FOREIGN  BODIES   IN   THE  BLADDER  463 

be  primary — or  it  may  have  formed  in  the  bladder  about  some 
other  foreign  body,  such  as  a  silk  ligature,  or  the  products  of 
inflammation.  In  the  latter  event  it  is  a  secondary  stone.  In- 
crustations of  phosphates  and  urates  on  the  bladder  walls  following 
inflammatory  processes  are  the  commonest  forms  of  calculi.  Small 
uric  acid  and  oxalic  acid  calculi  may  come  down  from  the  kidney, 
stay  in  the  bladder,  and  attain  considerable  size  by  the  accretion 
of  layers  of  deposit  of  urates  and  phosphates. 

Calculi  are  most  often  found  in  children  and  in  old  women. 

The  female  urethra  is  short  and  frequently  small  stones  from 
the  kidney  are  passed  without  causing  severe  symptoms.  On  the 


FIG.  186. — Stone  in  the  Bladder.     (Knorr.) 

other  hand,  foreign  bodies  are  introduced  from  without  much  more 
easily  than  in  the  male,  therefore  the  presence  of  extraneous 
foreign  bodies  and  consequently  of  some  form  of  stone — for  foreign 
bodies  are  usually  encrusted  after  they  have  been  in  the  bladder 
for  any  length  of  time — is  more  common  in  the  female  than  in  the 
male  bladder. 

Other  Foreign  Bodies. — Substances  introduced  through  the 
urethra  arc:  pieces  of  catheters  which  have  broken  off,  pieces 
of  rubber  tubing,  hairpins,  seeds  of  cherries  and  other  fruits.  It  is 
a  rare  but  not  impossible  occurrence  for  a  nurse  to  break  off  a  glass 
catheter  in  the  bladder.  Many  of  the  fencstrated  glass  catheters 
are  weakened  by  the  holes  of  the  fenestrations  being  too  near 


464  DISEASES  OF  THE  BLADDER 

together,  and  on  this  account  the  catheter  is  more  apt  to  be  cracked 
in  this  situation. 

Once,  ten  years  ago,  I  was  performing  an  abdominal  operation 
for  rctroversion  in  a  private  hospital.  This  operation  had  been 
preceded  at  the  same  sitting  by  a  curetting  and  trachelorrhaphy, 
and  the  precaution  of  passing  the  catheter  at  the  close  of  the  va- 
ginal operations  had  been  neglected  so  that  when  the  abdomen 
was  opened  the  bladder  was  found  to  be  full.  A  nurse  was  asked 
to  pass  the  catheter.  She  did  so,  using  a  fenestrated  glass  instru- 
ment of  the  common  pattern,  and  announced  that  there  was  no 
urine  in  the  bladder.  On  withdrawing  the  catheter,  however,  one 
and  a  quarter  inches  of  the  end  were  missing.  Removing  my 
gloves,  I  passed  another  catheter  and  withdrew  eight  ounces  of 
urine.  I  was  then  able  to  palpate  by  my  finger  in  the  vagina  the 
broken  catheter  lying  on  the  base  of  the  bladder.  Introducing 
an  Emmet  curette  forceps  through  the  urethra  I  succeeded  in 
pushing  the  broken  glass  into  the  forceps  by  means  of  my  finger 
in  the  vagina  so  that  it  lay  in  the  long  axis  of  the  fenestration  of 
the  blades.  The  catheter  end  was  removed  through  the  urethra 
without  injuring  the  bladder  or  urethra  in  the  slightest  degree. 
The  broken  piece  exactly  matched  its  fellow,  but  the  bladder  was 
irrigated  to  make  sure  that  no  spicule  of  glass  was  left  behind. 
The  operation  was  finished  and  the  patient  made  a  convalescence 
free  from  urinary  symptoms.  Since  this  accident  I  have  discarded 
this  form  of  glass  catheter  and  use  only  the  sort  that  has  a  single 
opening  in  the  end  or  side. 

Foreign  bodies  may  enter  the  bladder  from  the  vagina,  the  most 
common  of  these  being  a  neglected  pessary,  which  has  ulcerated 
through;  or  from  the  abdominal  cavity,  as  a  silk  ligature  which 
was  about  the  pedicle  of  an  ovarian  cyst,  then  became  infected 
and  reached  the  bladder  by  means  of  adhesive  inflammation;  or 
the  contents  of  a  dermoid  or  echinococcus  cyst  which  has  opened 
into  the  bladder.  The  bones  of  an  extra-uterine  fetus  have  been 
known  to  find  their  way  into  the  bladder. 

Foreign  bodies  which  remain  in  the  bladder  a  considerable 
length  of  time  invariably  set  up  a  cystitis.  This  process  may  be 
limited  to  a  portion  of  the  organ,  as  in  the  case  where  the  irritating 
foreign  body,  especially  in  the  case  of  stone,  is  situated  in  a  loculus. 
As  a  rule,  the  cystitis  is  general.  Large  foreign  bodies  have  been 


CYSTITIS  465 

known  to  ulcerate  through  the  bladder  into  the  vagina  or  into  the 
peritoneal  cavity. 

Symptoms. — The  symptoms  of  foreign  bodies  are  those  of  cys- 
titis: there  is  frequency  of  micturition,  pain  in  the  region  of  the 
bladder,  cloudy,  perhaps  bloody  urine.  A  stone  may  be  carried 
in  the  bladder  for  years  without  producing  any  more  symptoms 
than  a  frequency  of  micturition.  A  freely  movable  stone  causes 
exaggeration  of  symptoms  on  moving  about,  especially  on  riding 
and  driving;  it  may  be  at  these  times  only  that  the  urine  is  bloody. 

Diagnosis. — The  diagnosis  is  made  by  palpation  and  inspection. 
Many  foreign  bodies  may  be  felt  by  the  finger  in  the  vagina,  the 
obstacles  being  a  foreign  body  of  small  size  and  a  thickened  bladder 
wall.  The  base  of  the  bladder  should  be  palpated  always.  The 
sound  introduced  per  urethram  hits  a  stone  or  encrusted  foreign 
body  with  a  metallic  click.  Sometimes  a  stone  in  a  loculus,  or  one 
covered  with  a  thick  layer  of  mucus,  will  not  give  this  click  and 
phosphatic  deposits  on  an  ulcerated  area  give  a  grating  feeling  to 
the  sound  similar  to  that  of  a  round  calculus.  The  drumming  of 
the  bladder  wall  on  the  end  of  the  catheter — so-called  "stammering 
of  the  bladder,"  little  taps  being  given  to  the  catheter, — must  not 
be  mistaken  for  the  metallic  click.  This  drumming  is  a  physio- 
logical affair  and  may  occur  in  healthy  bladders  as  far  as  we  know 
at  present.  It  occurs  surely  in  the  course  of  catheterization  of 
patients  who  present  no  bladder  symptoms.  The  exact  diagnosis 
of  stone  is  made  by  means  of  the  cystoscope,  the  patient  being  in 
the  knee-chest  cystoscopic  position.  Unless  the  foreign  body  is 
adherent  to  the  bladder  wall  it  will  drop  to  the  most  dependent  part; 
in  any  event  it  may  be  seen  through  the  cystoscope. 

The  electric  cystoscope  with  water-distended  bladder  is  well 
adapted  for  the  inspection  of  small  calculi  and  especially  for  those 
that  are  pocketed.  (For  electric  cystoscopy  see  Chapter  VIII., 
page  117.) 

CYSTITIS 

Inflammation  of  the  bladder  is  much  more  infrequent  in  women 
than  in  men.  It  is  a  disease  of  adult  life  and  is  especially  common 
at  the  times  of  excessive  pelvic  congestion,  that  is,  during  the 
menstrual  periods,  in  pregnancy,  during  congestive  pelvic  disease, 

30 


466  DISEASES  OF  THE   BLADDER 

and  at  the  menopause.  True  cystitis  is  rare  during  childhood,  but 
bacteriuria  is  not  uncommon.  (See  Chapter  XXVIII.,  page  579.) 

Classification. — Cystitis  may  be  classified  as  acute  or  chronic, 
circumscribed  or  diffuse,  or  according  to  the  clinical  manifestations. 
Some  day  a  classification  based  on  the  bacteriology  will  be  the 
standard.  At  present  a  clinical  classification  seems  to  be  most 
available  for  diagnostic  purposes.  The  symptoms  of  cystitis  will 
be  considered  as  a  whole  after  the  different  clinical  forms  have 
been  described. 

Etiology  and  Pathology. — The  immediate  cause  of  cystitis  is 
always  a  bacterium.  Many  sorts  of  bacteria  are  found  in  the 
bladder  under  conditions  of  health,  just  as  in  the  cases  of  the 
other  orifices  of  the  body  that  are  lined  with  mucous  membrane. 
With  an  unimpaired  vis  medicatrix  nature  the  microorganisms 
are  short-lived,  instance  the  Klebs-Loeffler  bacillus  in  the  nose; 
given  impaired  vitality  and  the  germs  find  lodgment  and  flourish 
in  the  tissues.  The  following  bacteria  have  been  isolated  from 
the  bladder,  almost  always  in  mixed  infections: 

bacillus  coli  communis,  gonococcus, 

streptococcus  pyogencs,  typhoid  bacillus, 

staphylococcus  pyogenes,  tubercle  bacillus, 

staphylococcus  albus,  bacillus  proteus, 

staphylococcus  aureus,  bacillus  lactis  aerogenes, 

staphylococcus  citrous,  bacillus  pyocyaneus, 

urobacillus  liquefaciens. 

In  other  words,  almost  any  bacterium  may,  under  favorable 
conditions,  enter  the  bladder  and  cause  a  cystitis.  What  are  the 
avenues  of  entrance  and  what  are  the  favorable  conditions?  The 
microorganism  may  reach  the  bladder  (a)  through  the  urethra, 
as  in  the  case  of  the  gonococcus,  which,  as  far  as  known,  always 
gets  into  the  bladder  by  this  channel,  (6)  through  the  ureter,  as  in 
the  case  of  the  tubercle  bacillus,  which  usually  descends  to  the 
bladder  in  this  way,  (r)  by  the  blood  current, — the  typhoid  bacillus 
may  come  in  the  blood,  and  (d)  by  direct  extension  through  the 
tissues  from  an  adjoining  organ,  as  in  the  case  of  the  bacillus  coli 
communis  entering  the  bladder  tlrrough  the  walls  of  an  adherent 
and  inflamed  bowel. 


CYSTITIS  467 

The  favorable  conditions — the  predisposing  causes — are:  (1) 
local,  or  (2)  general.  1.  Local  causes  are  injuries  of  the  bladder, 
either  direct  trauma  inflicted  on  its  mucous  membrane,  or  on  the 
musculature  of  the  wall,  as  instrumentation  during  difficult  labor, 
rough  catheterization  with  a  hard  catheter,  or  from  stone  or  other 
foreign  body  in  the  bladder,  or  by  displacements  of  the  bladder, 
as  from  the  injuries  resulting  from  childbirth,  from  tumors,  or  from 
overdistention.  Pregnancy  and  the  catamenia  must  be  regarded 
as  local  causes,  for  at  these  times  the  congestion  of  the  pelvic 
organs  is  pronounced,  and  observation  has  shown  that  cystitis  is 
more  apt  to  begin  then,  and  if  it  has  existed  previously  exacer- 
bations are  more  common  both  just  before  the  menstrual  periods 
and  during  pregnancy  and  the  puerperium.  Anything  that  excites 
and  continues  congestion  of  the  pelvic  organs  must  be  regarded  as 
a  cause  of  cystitis,  and  therefore  excessive  venery  or  masturbation 
may  have  an  etiological  significance.  Inflammation  of  adjacent 
organs  is  a  local  cause  in  many  gynecological  cases,  as  inflammation 
of  the  tubes,  a  pelvic  abscess,  or  dermoid  cyst  discharging  into  the 
bladder,  or  uterine  cancer. 

2.  Among  the  general  causes  are  to  be  classed  certain  drugs 
taken  by  the  mouth,  as  cantharides  and  turpentine,  which  cause 
congestion  of  the  vesical  mucosa  and  therefore  are  causes  of  in- 
flammation, also  alcohol  taken  in  excess.  Lowered  vitality  and 
anemia  are  caused  by  the  wasting  diseases,  also  by  any  acute 
disease.  Skene  said  that  he  had  noted  that  in  measles  and  scarlet 
fever  the  mucous  membrane  of  the  bladder  suffered  like  the  mu- 
cous membranes  elsewhere  in  the  body  in  these  diseases. 

Chronic  heart  disease  and  cirrhosis  of  the  liver  produce  engorge- 
ment of  the  pelvic  organs;  old  age,  by  diminishing  the  tonicity 
of  the  bladder  walls,  favors  retention  and  decomposition  of  urine; 
and  paralysis,  in  the  same  way,  may  promote  retention,  overdis- 
tention, and  decomposition.  Major  operations,  by  depressing  the 
strength  and  powers  of  resistance  of  the  system,  may  be  reckoned 
among  the  causes.  "Catching  cold"  must  be  regarded  as  a  local 
congestion  of  unknown  origin,  which  often  is  the  only  cause  afforded 
by  the  history  of  the  case. 

Catarrhal  Cystitis. — The  mucous  membrane  of  the  bladder  is  of 
a  deeper  shade  of  pink  than  normal,  and  there  is  an  increase  in  the 
number  and  the  size  of  the  visible  blood-vessels.  The  condition  is 


4G8  DISEASES  OF  THE  BLADDER 

an  exaggeration  of  the  hypcrcmia  seen  during  menstruation  and 
pregnancy.  No  one  can  say  when  hypcremia  shades  into  inflamma- 
tion, therefore  very  little  will  be  said  of  hyperemia  and  local  hypere- 
mia  of  the  trigone,  for  instance,  and  "trigonitis"  will  be  classed 
as  localized  cystitis. 

Ulcerative  Cystitis. — With  ulceration  there  is  a  loss  of  epithelium 
in  the  mucous  membrane.  An  excavation  can  be  seen  lined  by 
granulation  tissue,  which  bleeds  on  the  slightest  touch.  There 
may  be  pus,  granular  debris,  or  urinary  salts  on  the  surface  of  an 
ulcer,  and,  hi  the  healing  stage,  ridges  and  irregular  elevations  are 
visible. 

Exfoliative  Cystitis. — This  is  a  rare  form  of  cystitis  in  which  the 
mucosa  is  shed  in  part  or  as  a  whole,  with  subsequent  regeneration. 
It  is  due,  apparently,  to  the  cutting  off  of  the  blood  supply  of  the 
bladder  caused  most  often  by  retroflexion  of  the  pregnant  uterus, 
or  by  protracted  delivery.  It  is  an  ischemic  necrosis,  with  or 
without  bacterial  infection.  .  The  detached  mucous  membrane  is 
passed  per  urethram  either  in  small  pieces  or  in  one  large  piece, 
and  is  apt  to  be  covered  by  uric  acid  crystals  and  to  be  so  much 
disorganized  that  the  recognition  of  it  as  mucous  membrane  is  not 
easy.  In  severe  grades,  as  pointed  out  by  Boldt,  the  muscular  or 
even  the  peritoneal  coats  of  the  bladder  may  be  involved. 

Tuberculous  Cystitis. — Tuberculous  cystitis  is  a  frequent  affection 
and,  in  the  vast  majority  of  cases,  is  secondary  to  tuberculous 
disease  of  the  kidney,  the  infection  coming  to  the  bladder  through 
the  ureter.  Rarely  it  is  primary  in  the  bladder,  and  it  may  be  a 
part  of  a  general  tuberculosis.  If  the  disease  is  secondary  to 
tuberculosis  of  the  kidney  the  manifestations  in  the  bladder  are 
most  marked  in  the  neighborhood  of  the  ureteral  orifice  on  the  side 
of  the  affected  kidney,  because  in  this  situation  the  infected  un- 
diluted urine  comes  into  most  intimate  contact  with  the  mucosa. 
Tuberculosis  of  the  kidney  is  generally  unilateral  in  its  earlier  stages. 
The  ureteral  mons  is  puffy  and  swollen,  and  glistening  opaque 
tubercles  and  ulcerations  are  seen  in  the  mucosa  surrounding  the 
orifice.  The  disease  is  seldom  seen  before  the  ulcerative  stage, 
although  there  is  a  catarrhal  stage  which  precedes  it.  In  the 
course  of  time  caseation  occurs  and  the  tubercles  break  down, 
leaving  a  deep,  ragged-edged  ulcer;  the  urine  containing  pus,  blood, 
and  mucus.  The  disease  may  be  confined  to  definite  patches  in 


CYSTITIS  469 

the  bladder;  the  trigone,  base,  and  posterior  walls  being  most 
often  involved;  the  liberations  advance  slowly  in  any  event;  in 
very  bad  cases  the  entire  bladder  may  be  ulcerated. 

The  disease  runs  a  chronic  course  of  many  years'  duration.  In 
making  the  diagnosis  of  tuberculous  cystitis  the  history  is  of  aid, 
and  if  gonorrhea  can  be  ruled  out  in  a  patient  having  a  distinct 
family  history  of  tuberculosis,  the  probability  is  that  the  disease 
is  tuberculous,  especially  if  the  cystitis  occurs  in  a  young  woman. 
The  appearances  of  the  bladder  are  more  or  less  characteristic: 
glistening,  opaque  tubercles  on  a  reddened  base,  breaking  down 
to  form  ulcers  with  irregular  sharp  edges  and  granulating  bases. 


FIG.   187. — Tuberculosis  of  the  Left  Ureter  and  Bladder,  Showing  Crater-like 
Ureteral  Orifice  and  Tubercles  of  the  Bladder  Wall.     (Knorr.) 

In  the  late  stages  the  bladder  shows  contracted  areas  and  ulcera- 
tions.  Finding  the  tubercle  bacilli  in  the  urine  makes  the  diagnosis 
positive.  In  the  early  stages  of  the  disease  they  may  be  few  in 
number  and  hard  to  find;  later,  there  will  be  no  difficulty,  as 
abundant  bacilli  are  in  the  urinary  sediment. 

Hunner  and  Casper  have  been  able  to  find  tubercle  bacilli  in 
eighty  per  cent  of  all  their  cases  of  tuberculosis  of  the  urinary  sys- 
tem. Hunner  gives  the  following  steps  of  his  technique  for  finding 
the  bacilli: — A  catheterized  specimen  of  urine  is  allowed  to  stand  a 
few  hours  in  a  conical  urine  glass;  5  to  10  cubic  centimeters  are 
taken  from  the  bottom  with  a  pipette  and  centrifugalized.  The 
heavy  deposit  is  spread  on  two  glass  slides  that  have  been  pre- 


470  DISEASES  OF  THE  BLADDER 

viously  cleansed  of  grease  by  alcohol,  and  are  allowed  to  dry  in 
the  air  or  in  the  incubator.  These  slides,  after  fixing  by  heat,  are 
stained  in  the  usual  manner  by  carbol-fuchsin,  then  they  are 
decolorized  with  athree-per-cent  nitric  or  hydrochloric  acid  alcohol 
solution,  and  counterstained  with  methylene  blue.  Half  an  hour 
is  spent  in  the  examination  of  each  slide  under  the  microscope. 

Inoculation  of  a  guinea-pig  is  an  easy  and  sure  way  of  estab- 
lishing the  diagnosis  of  tuberculous  cystitis.  By  means  of  a  hypo- 
dermic syringe  suck  up  a  little  of  the  urinary  sediment  and  inject 
it  under  the  skin  of  the  groin  of  a  guinea-pig,  having  first  washed 
and  shaved  the  area.  If  tubercle  bacilli  are  present  the  enlarged 
inguinal  glands  will  be  felt  as  distinct  nodules  in  the  course 
of  two  or  three  weeks.  A  gland  removed,  sectioned,  and  stained 
will  show  the  characteristic  lesions  of  tuberculosis  and  the 
tubercle  bacilli. 

In  doubtful  cases  pick  off  a  bit  of  tissue  from  the  edge  of  the 
ulcerated  area  in  the  bladder,  using  the  cystoscope  and  the  alligator 
forceps,  and  stain  and  examine  the  tissue  for  tubercle  bacilli. 

Rare  Forms. — Certain  rare  forms  of  cystitis  have  been  described. 
Of  these  vesicular  cystitis  consists  of  the  appearance  of  minute 
vesicles,  the  size  of  a  pin's  head,  on  a  congested  bladder  mucosa. 
These  vesicles  may  be  arranged  in  bead-like  strings  on  either  side 
of  the  blood-vessels  and  are  regarded  as  dilated  lymphatics.  Larger 
vesicles  amounting  to  bulhc  have  been  described  as  occurring  in 
the  bladder.  The  little  vesicles  arc  not'  to  be  confused  with  the 
tubercles  of  tubercular  cystitis.  The  vesicles  are  shiny,  translu- 
cent, and  have  no  red  base,  as  in  the  case  of  the  tubercle.  The 
tubercles  are  opaque  and  are  never  arranged  in  rows. 

Several  observers  have  noted  the  occurrence  in  the  bladder  of  a 
patch  of  horny,  epithelial  cells  arranged  in  layers,  a  cornification 
of  the  mucosa.  A.  T.  Cabot  (Amer.  Jour.  Med.  Sci.,  Feb.,  1891) 
described  a  case  in  which  a  membrane  of  whitish-yellow  color  and 
hard  to  the  touch,  in  size  forty-five  square  centimeters  and  two 
or  three  millimeters  in  thickness,  was  removed  by  him  from  the 
posterior  wall  of  the  bladder  of  a  man  of  forty  by  suprapubic 
cystotomy.  The  membrane  was  composed  of  epithelial  cells 
arranged  as  they  are  on  the  surface  of  the  skin.  Virchow  found  a 
similar  condition  of  the  mucous  membrane  of  the  larynx  that  he 
called  "pachydermia  laryngis." 


CYSTITIS  471 

Gierke,  according  to  Hunner,  described  two  cases  and  found 
seven  others  in  the  literature  with  the  following  characteristics:— 
Soft  nodules  or  plaques  of  a  yellowish  or  yellowish-gray  color  sit- 
uated in  the  mucous  membrane  and  submucosa  of  the  bladder 
presenting  an  appearance  not  unlike  the  Peyer's  patches  of  the 
intestine  in  typhoid  fever.  They  are  round  or  oval,  isolated  or 
connected,  and  vary  in  size  from  one  millimeter  to  two  centimeters 
in  diameter.  The  mucosa  surrounding  a  plaque  is  reddened.  They 
have  no  characteristic  arrangement  arid  their  pathology  and  etiology 
are  obscure. 

Symptoms  of  Cystitis. — The  chief  symptom  of  cystitis  is  frequency 
of  passing  urine  accompanied  by  pain,  it  being  most  marked  when 
the  seat  of  the  disease  is  near  the  neck  of  the  bladder.  The  frequency 
varies  under  differing  conditions  and  at  different  times,  from  once 
an  hour  to  every  five  minutes.  There  may  be  great  straining  on 
urination  with  the  passage  of  only  a  few  drops  of  urine  at  a  time. 
This  is  known  as  strangury  (from  ffrpd^}  a  drop,  and  oup<>v}  urine). 
Patients  of  a  nervous  temperament  suffer  more  acutely  with  a 
milder  grade  of  bladder  inflammation  than  do  their  thicker-skinned, 
more  stoical  sisters  with  a  cystitis  of  severe  type.  Hyperemia  of 
the  trigone  may  be  associated  with  frequency  and  even  with  pain- 
ful micturition.  An  important  factor  in  the  symptomatology  as 
regards  its  effect  on  the  nervous  system  is  the  patient's  fear  that  a 
toilet  may  not  be  accessible  when  the  desire  to  urinate  comes, 
therefore  she  stays  at  home,  becomes  a  recluse,  and  is  melan- 
cholic. Loss  of  sleep  because  of  frequency  of  micturition  is  another 
important  factor  to  consider  in  cases  of  cystitis  in  deciding  as  to 
the  causation  of  nervous  debility.  More  or  less  constant  pain  in 
the  region  of  the  bladder  is  a  symptom  of  an  ulcer  of  the  base  of 
the  bladder.  An  ulcer  or  fissure  may  be  painful  only  when  the 
bladder  is  distended  and  the  walls  of  the  bladder  are  on  the  stretch 
and  the  surface  of  the  ulcer  or  fissure  is  bathed  in  irritating  urine. 
A  rise  of  temperature  may  occur  in  acute  cystitis,  but  in  the  chronic 
stages  fever  is  generally  absent.  It  may  occur,  however,  in  pyelitis, 
and  irregular  elevation  of  temperature  should  lead  suspicions  in 
that  direction. 

Diagnosis  of  Cystitis. — The  diagnosis  rests  on  the  results  of  the 
examination  of  the  urine  and  on  the  physical  examination. 

The  Examination  of  the  Urine. — The  urine  in  cystitis  is  cloudy 


472  DISEASES  OF  THE  BLADDER 

and  contains  pus  and  large  pavement  epithelial  cells.  Other  vari- 
able constituents  are  blood — normal  and  abnormal — uratcs,  phos- 
phates, crystals,  and  bacteria.  To  be  sure  that  pus  in  the  urine  is 
from  the  bladder  and  not  from  the  external  genitals  or  the  vagina 
it  is  necessary  to  procure  a  catheter  specimen,  and  even  then  the 
point  of  origin  of  the  pus  may  be  the  ureter  or  the  kidney.  If  there 
are  present  casts,  a  large  amount  of  albumin,  and  small  epithelial 
cells,  also  if  the  passing  of  urine  filled  with  pus  alternates  with 
the  passing  of  clear  urine,  the  indications  point  toward  kidney 
disease.  Kelly  has  called  attention  to  the  fact  that  when  the 
bladder  urine  is  alkaline  from  a  protcus  infection  the  pus  cells 
become  converted  into  mucoid  substances  and  the  urine  is  slimy 
and  stringy,  while  no  well-defined  pus  cells  are  found  in  the  urine. 
The  presence  of  abnormal  blood  in  the  urine  signifies  that  the 
blood  has  been  in  the  urine  a  considerable  time,  and  therefore  its 
origin  is  more  likely  to  be  the  kidney  than  the  bladder.  If  blood 
is  effused  rapidly,  however,  it  will  appear  in  the  urine  as  normal 
blood,  be  its  origin  the  bladder  or  the  kidney. 

In  almost  all  cases  of  cystitis  the  urine  is  acid  when  freshly  passed, 
but  it  quickly  becomes  alkaline  on  standing.  In  some  cases  the 
urine  in  the  bladder  is  made  alkaline  by  the  bacillus  proteus  or 
other  bacteria.  This  happens  in  cases  of  dislocated  bladder  where 
there  is  present  residual  urine.  There  is  nothing  distinctive  about 
the  specific  gravity  of  cystitis  urine,  and  many  of  the  old  views 
as  to  its  characteristics  must  be  revised  in  the  light  of  our  present 
knowledge  of  the  bacterial  origin  of  all  forms  of  cystitis. 

The  odor  of  a  cystitis  urine  is  strong  and  may  smell  of  decom- 
position even  though  the  colon  bacillus  is  present  and  the  reaction 
is  acid.  There  may  be  gas  in  the  urine  caused  by  the  decomposition 
of  diabetic  urine  due  to  the  saccharomyces  bacterium,  or  to  the 
presence  in  the  bladder  of  the  gas  bacillus,  also  in  cases  where 
there  is  a  fistula  connecting  the  bowels  with  the  bladder. 

Palpation.— Palpation  of  the  bladder  by  the  bimanual  touch 
elicits  areas  of  tenderness,  especially  if  the  cystitis  is  situated  in 
its  common  location,  the  base  of  the  bladder.  Such  areas  may 
be  mapped  out  by  means  of  the  catheter-sound  in  the  bladder, 
the  patient  telling  when  the  sensitive  spot  is  touched.  Thickening 
of  the  bladder  wall  is  appreciated  by  palpating  the  base  of  the 
bladder  with  the  finger  in  the  vagina,  and  also  by  noting  the 


CYSTITIS  473 

thickness  of  the  tissues  between  the  tip  of  the  sound  in  the  bladder 
and  the  vaginal  finger;  a  contracted  bladder  may  be  felt  as  a  hard, 
irregular  lump.  In  acute  cystitis  vaginal  palpation  shows  that 
the  bladder  is  the  seat  of  extreme  tenderness,  but  further  than 
that  palpation  is  not  available  without  an  anesthetic. 

Cystoscopy. — Cystoscopy  may  be  employed  in  all  cases  of  cystitis 
except  in  the  most  acute  stages.  Here  it  is  wiser,  generally,  to 
make  soothing  treatments  until  the  active  symptoms  of  fever, 
strangury,  and  excessive  tenderness  have  abated,  before  using 
the  cystoscope.  The  use  of  cocaine  in  the  urethra  and  the  knee- 
chest  position  as  described  in  Chapter  VIII. ,  page  110,  best  facili- 
tate inspection  of  the  interior  of  the  bladder.  In  the  case  of  trigo- 
nitis  and  the  milder  grades  of  bladder  inflammation  the  artificial 
anemia  caused  by  the  high  position  of  the  pelvis,  coupled  with 
the  air  distention  of  the  viscus,  tend  to  do  away  with  the  character- 
istic signs,  therefore  in  these  cases  the  raised  pelvis  dorsal  position 
should  be  used. 

All  parts  of  the  bladder  should  be  examined  systematically  in 
order.  Free  blood  is  wiped  off  the  surface  by  minute  pledgets  of 
cotton  held  in  the  alligator  forceps  and  thus  is  made  plain  the 
difference  between  blood  on  the  surface  of  the  mucosa  and  blood 
effused  in  the  tissues.  Collected  urine  is  removed  by  the  suction- 
tube  and  bits  of  urinary  salts  obstructing  the  view  are  taken  away 
with  the  alligator  forceps.  If  the  disease  is  localized  the  congested, 
diseased  areas  of  the  bladder  wall  are  contrasted  with  the  paler, 
healthy  parts.  Cultures  are  made  from  ulcerated  areas,  the  ure- 
teral  orifices  are  inspected,  and  the  character  of  the  fluid  issuing 
from  them  is  noted.  It  is  never  justifiable  to  pass  a  ureteral  catheter 
into  a  presumably  healthy  ureter  in  the  presence  of  acute  or  sub- 
acute  cystitis,  until  the  nature  of  the  infection  in  the  bladder  is 
known,  because  of  the  great  danger  of  carrying  infection  into  the 
ureter,  and  until  all  other  attainable  facts  as  to  the  existence  of 
kidney  disease  are  in  hand  the  physician  should  be  content  not 
to  invade  the  ureters.  In  the  presence  of  infection  the  bladder 
should  be  irrigated  with  sterile  one-per-cent  boric  acid  solution 
before  ureteral  catheters  are  passed  and  such  an  irrigation  should 
be  the  last  step  in  the  cystoscopy. 


474  DISEASES  OF  THE  BLADDER 


VARIX  OF  THE  BLADDER 

Varicose  veins  of  the  bladder  is  a  very  rare  condition,  although 
from  a  priori  considerations  it  should  be  common.  It  has  been 
found  in  men  associated  with  rectal  hemorrhoids.  Knorr  shows 
in  his  book  a  beautiful  plate  of  a  varix  in  the  neighborhood  of  the 
right  ureteral  orifice  as  seen  through  the  electric  cystoscope.  Hem- 


FIG.  188. — Varix  of  the  Bladder  near  the  Opening  of  the  Right  Ureter.     (Knorr.) 

orrhage  from  the  bladder  is  the  chief  symptom,  and  difficulty  of 
urination  may  be  present.  Cystoscopy  affords  the  only  opportunity 
for  an  exact  diagnosis. 


FISTULA  OF  THE  BLADDER 

A  vesical  fistula  is  an  abnormal  channel  of  communication 
between  the  bladder  and  an  adjacent  organ.  Fistula)  are  of  three 
sorts: — 1.  Vesico- vaginal,  2.  vesico-uterine,  3.  vesico-intestinal  and 
other  fistulac. 

1.  VESICO  VAGINAL  FISTULA 

Frequency,  Etiology,  and  Pathology. — Vcsico- vaginal  fistula)  vary 
in  size  from  a  pin-point  opening  to  a  large  hole  involving  the 
entire  base  of  the  bladder.  The  cervix  may  be  involved,  in  which 


FISTULA   OF  THE   BLADDER  475 

case  the  fistula  becomes  vesico-uterine  as  well  as  vesico-vaginal. 
The  opening  is  generally  situated  in  the  median  line  in  the  case  of  a 
fistula  involving  the  cervix  as  well  as  the  vagina,  according  to 
Thomas  Addis  Emmet  ("Vesico- Vaginal  Fistula,"  1868).  In 
other  fistula)  the  opening  may  be  in  any  part  of  the  vesico-vaginal 
septum.  It  is  irregular  in  outline  in  the  months  following  its 
formation  and  the  edges  are  thickened  and  ulcerated;  later,  the 
opening  is  circular  or  oval  and  the  edges  are  smooth,  thin,  and 
hard,  the  tendency  of  the  fistula  being  to  close  by  granulation  and 
cicatrization.  A  clean-cut  fistula  formed  artificially  by  operation 
for  the  purpose  of  draining  the  bladder  in  cases  of  cystitis  will  close 
spontaneously  in  a  short  time  unless  the  operator  takes  the  pre- 
caution to  stitch  the  cut  edges  of  the  bladder  mucosa  to  the  edges 
of  the  vaginal  mucous  membrane.  A  small  opening  which  has  been 
caused  by  sloughing  may  close  of  itself,  but,  in  many  cases,  these 
are  the  fistulse  that  persist  for  years. 

In  the  case  of  large  fistulaa  there  may  be  present  cicatricial 
bands  radiating  from  the  fistula  over  the  bladder  walls.  Vesico- 
vaginal  fistulse  are  the  most  common  of  the  fistulse  of  the  genital 
tract.  They  are  not  nearly  so  common  as  they  used  to  be  forty 
years  ago.  During  the  first  twelve  years  of  the  Woman's  Hospital 
in  the  State  of  New  York  up  to  the  year  1868,  Dr.  Emmet  had 
under  his  charge  296  cases  of  genital  fistulse,  including  in  this 
number  the  cases  of  vesico-uterine  and  recto-vaginal  fistula,  the 
last,  however,  forming  only  about  six  per  cent  of  the  whole. 
At  the  present  time  I  venture  to  say  that  few  gynecologists  having 
an  active  hospital  service  and  a  large  private  practice  see  more 
than  two  or  three  cases  of  vesico-vaginal  fistula  in  the  course  of  a 
year.  A  perusal  of  the  recent  annual  reports  of  half  a  dozen  metro- 
politan hospitals  having  large  gynecological  clinics  reveals  the  fact 
that  in  no  one  hospital  were  more  than  three  cases  of  vesico-vaginal 
fistula  seen  during  any  one  year. 

The  cause  of  vesico-vaginal  fistula  is,  in  a  vast  majority  of  cases, 
ischemic  necrosis  of  the  vesico-vaginal  septum  due  to  impaction  of 
the  child's  head  in  the  pelvis  during  prolonged  labor.  Very  rarely 
fistula  may  result  from  the  use  of  the  obstetric  forceps.  Emmet 
saw  only  three  cases  when;  this  had  occurred.  It  is  possible  that 
at  the  present  time  when  forceps  are  used  more  frequently  and 
women  are  neglected  in  labor  less  often,  injuries  from  instruments 


476 


DISEASES  OF  THE  BLADDER 


may  occur  with  relatively  greater  frequency.  If  the  forceps  or 
other  instruments  cause  the  fistula  there  will  be  a  discharge  of 
urine  immediately  after  labor,  otherwise  not  until  the  slough  has 
separated — in  a  week  or  ten  days.  In  two  cases  that  I  operated  on 
for  extensive  vesico-vaginal  fistula  there  was  a  history  of  incon- 
tinence of  urine  following  immediately  after  a  difficult  forceps 


i'jc.  189.— Diagrammatic    Representation    of   the   Different   Sorts   of   Genital 

Fistula;.     (Dudley.) 

delivery  in  each  instance.  Embryotomy  had  been  performed  in 
one.  Other  causes  of  vesico-vaginal  fistula  arc :  sloughing  resulting 
from  rancor  of  the  bladder,  from  a  large  vesical  calculus  or  from 
an  ill-fitting  pessary,  or  the  burrowing  of  a  pelvic  abscess. 

Symptoms.— The  symptoms  of  vesico-vaginal  fistula  consist  of  a 
constant  dribbling  of  urine,  beginning  at  once  after  the  receipt  of 
the  injury  if  it  is  due  to  forceps  or  other  obstetrical  instruments 


FISTULA   OF  THE   BLADDER  477 

and  in  a  week  or  ten  days  if  due  to  a  slough  from  prolonged  pressure 
and  ischemia  of  the  vesico-vaginal  septum.  In  the  latter  event 
we  expect  to  find  present  a  rise  of  temperature  and  a  purulent 
vaginal  discharge.  The  skin  of  the  vulva,  perineum,  and  the 
insides  of  the  thighs  is  excoriated,  reddened,  and,  in  cases  of  long 
standing,  thickened.  The  hairs  of  the  vulva  and  the  edges  of  the 
fistula  are  encrusted  with  urinary  salts. 

The  patient  suffers  extremely  from  the  irritation  caused  by  the 
urine  and  from  being  constantly  wet  and  deprived  of  proper  rest, 
so  that  the  nervous  system  is  deranged  and  in  many  cases  she 
becomes  melancholic.  The  nutrition  is  impaired,  and  cachexia  and 
poor  health  result. 

If  the  vaginal  outlet  is  uninjured,  as  occasionally  happens,  some 
patients  with  vesico-vaginal  fistula  are  able  to  retain  a  considerable 
amount  of  urine  in  the  vagina  while  lying  down,  the  urine  being 
passed  when  the  patient  assumes  the  erect  posture.  The  subject 
of  a  vesico-vaginal  fistula  may  become  pregnant,  an  event  that 
occurred  in  a  patient  who  was  under  my  observation,  and  Winckel 
has  reported  an  instance  of  a  woman  with  a  vesico-vaginal  fistula 
who  became  pregnant,  was  delivered  at  term,  and  subsequently 
the  fistula  healed  spontaneously. 

Diagnosis. — The  patient  should  be  placed  first  in  the  dorsal 
position.  If  there  is  dermatitis  of  severe  grade  it  will  be  advisable 
to  treat  this  condition  before  making  an  exact  diagnosis.  To 
this  end  the  urinary  salts  should  be  removed  carefully,  the  parts 
bathed  in  boric  acid  solution — one  per  cent — and  thoroughly 
dried  with  soft  lint,  a  pledget  of  cotton  being  placed  temporarily 
in  the  vagina  if  necessary  to  prevent  urine  from  coming  out  until 
the  parts  are  dry.  Then  all  the  region  of  the  vulva  and  insides  of 
the  thighs  and  also  the  introitus  vagina)  should  be  smeared  with 
a  freshly  made  ointment  of  oxide  of  zinc.  This  treatment  should 
be  repeated  twice  a  day  and  the  vulva  should  be  constantly  covered 
with  soft  napkins  of  washed  cheese  cloth  or  old  linen,  the  attempt 
being  made  to  keep  the  parts  as  dry  as  possible.  Prolonged,  hot 
six-quart  vaginal  douches  should  be  given  twice  a  day  before  the 
drying  and  the  treatment  with  the  ointment.  Dr.  Emmet  always 
laid  much  stress  on  the  douches  and  said  that  his  good  results 
with  vesico-vaginal  fistula  depended  in  large  measure  on  the  faith- 
fulness of  the  nurse.  The  urine  should  be  kept  diluted  by  giving 


478  DISEASES  OF  THE  BLADDER 

much  fluid  by  the  mouth — milk  is  especially  valuable  in  these 
cases — and  rendered  unirritating  and  aseptic  by  the  adminis- 
tration of  urotropin,  ten  grains  every  four  hours. 

With  the  patient  in  the  Sims  position  and  with  a  Sims  speculum 
in  the  vagina  the  fistula  may  be  inspected,  note  being  taken  of  its 
size,  the  condition  of  the  edges,  whether  inflamed  and  thickened, 
or  encrusted  with  salts,  or  cicatricial  and  thin.  The  situation  of 
the  ureteral  orifices  should  be  determined  in  every  case  so  that 
they  may  not  be  included  in  the  line  of  sutures  when  repair  is 
undertaken.  Also,  if  the  opening  is  of  sufficient  size,  the  condition 
of  the  bladder  wall  may  be  seen,  whether  free  from  lime  salts  and 
how  much  inflamed  and  the  openings  of  the  ureters  may  be  in- 
spected directly.  The  capacity  of  the  bladder,  whether  contracted 
or  not,  is  determined  by  passing  a  sound  through  the  urethra 
and,  in  the  case  of  a  large  opening,  by  exploration  with  the  finger 
passed  through  the  fistula. 

In  the  case  of  very  small  fistula?  nothing  but  a  fine  probe  can 
be  passed  through  the  opening.  In  this  event  the  probe  is  intro- 
duced into  the  bladder  through  the  urethra  and  an  attempt  is  made 
to  cause  its  point  to  emerge  in  the  vagina.  In  these  cases  it  is 
well  to  put  the  patient  in  the  elevated  pelvis  position  and  perform 
cystoscopy  in  an  attempt  to  see  the  fistulous  opening  and  probe 
it  with  the  ureteral  searcher.  At  the  same  time  the  condition  of 
the  bladder  mucosa  is  inspected.  In  the  case  of  minute  fistula? 
which  can  not  be  found  with  the  probe,  inject  the  bladder  with 
milk  and  water  or  with  aniline  blue  and  water,  the  patient  being 
in  the  dorsal  position  and  a  speculum  in  the  vagina,  and  watch  for 
the  appearance  of  the  colored  fluid  from  the  opening  in  the  vaginal 
wall.  Knowing  the  situation  of  the  fistula  a  fine  probe  can  almost 
always  be  passed  through  it.  The  amount  of  scar  tissue  in  the 
vagina  must  be  determined  carefully  because  the  repair  depends 
on  the  amount  of  freely  movable  tissues  at  the  disposal  of  the 
operator.  The  scar  tissue  is  felt  by  the  palpating  finger  as  a  hard- 
ened and  roughened  area.  The  finger  introduced  through  a 
fistulous  opening  into  the  bladder  feels  the  velvety  mucous  mem- 
brane of  the  bladder  and  also  the  rough  lime  salts,  if  they  are 
present. 

Differential  Diagnosis. — A  vesico-vaginal  fistula  must  be  differ- 
entiated from  a  ureteral  fistula  into  the  vagina. 


FISTULA   OF  THE  BLADDER  479 

In  the  latter  event  there  will  be  a  history  of  discharge  of  urine 
in  the  natural  way  and  also  of  a  more  or  less  constant  leaking. 
Injecting  the  bladder  with  milk  and  water  and  drying  the  vagina, 
search  is  made  for  an  opening  in  the  vaginal  vault  that  gives  exit 
to  fluid  having  the  odor  of  urine.  If  urine  escapes  from  the  os 
uteri,  a  vesico-uterine  fistula  is  the  diagnosis.  In  cases  of  doubt 
inject  the  bladder  with  milk  and  water  and  then  see  it  issue  from 
the  os.  Don't  pass  a  ureteral  catheter  or  probe  into  a  suspected 
ureteral  fistula  nor  into  the  ureteral  orifice  in  these  cases,  because 
of  the  danger  of  infecting  the  ureter  and  causing  ureteral  and 
renal  disease. 

2.  VESICO-UTERINE  FISTULA 

This  form  of  fistula  is  not  so  common  as  vesico-vaginal  fistula 
and  is  more  often  due  to  a  direct  tear  from  the  uterus  into  the 
bladder  during  labor,  than  to  sloughing  following  bruising  of  the 
tissues.  The  lower  portion  of  the  tear  through  the  cervix  generally 
heals,  leaving  a  fistulous  opening  above.  The  symptoms  are 
dribbling  of  urine  more  or  less  constantly.  Some  of  the  urine  may 
be  passed  through  the  urethra  and  yet  there  may  be  a  leaking. 
Filling  the  bladder  with  milk  and  water  and  noting  that  the  white 
fluid  comes  from  the  os  uteri  establishes  the  diagnosis,  also  passing 
a  sound  or  probe  through  the  urethra,  the  end  is  passed  through 
the  bladder  fistula  into  the  uterus.  Another  sound  passed  into  the 
uterine  cavity  through  the  cervical  canal  meets  the  first  sound 
with  a  metallic  click  and  imparts  a  sensation  of  contact  to  the 
first  sound  or  probe. 

Vesicc-utero-vaginal  fistula  consists  of  an  opening  between 
bladder,  cervix,  and  vagina  resulting  from  extensive  injury  of  the 
cervix.  Kmmet  thought  it  of  more  frequent  occurrence  in  women 
who  have  borne  a  number  of  children  and  have  relaxed  abdominal 
walls.  The  defect  is  apt  to  be  found  partially  bridged  over  by 
granulation  and  cicatrization,  or  it  may  be  entirely  closed  with 
the  exception  of  a  small  fistula  in  the  lower  cervix. 

3.  YKSICO-IXTESTIXAL  AND  OTHER  FISTULA 

Cases  of  communication  between  the  bladder  and  the  intestine 
have  been  reported  but  they  are  rare  and  most  commonly  follow 


4SO  DISEASES  OF  THE  BLADDER 

operative  procedures.  R.  Harrison  reported  a  case  of  fistula 
between  the  colon  and  the  bladder  in  which  bubbles  of  gas  escaped 
through  the  urethra,  and  C.  P.  Noble  published  a  case  of  recto- 
vesical  fistula  following  an  ischio-rectal  abscess,  which  had  existed 
five  years  before.  Gas  and  pieces  of  fecal  matter  were  passed  per 
urcthram. 

An  abscess  of  the  Fallopian  tube  or  of  the  ovary  may  open  into 
the  bladder,  and  not  very  infrequently  a  suppurating  dermoid 
tumor  discharges  in  this  way.  The  presence  of  cystitis  and  finding 
the  contents  of  a  dermoid,  such  as  teeth,  bone,  or  hair,  in  the 
bladder,  or  if  passed  from  the  urethra,  points  to  the  seat  of  fistula. 
Bone  from  a  macerated  extra-uterine  fetus  has  been  known  to 
find  its  way  into  the  bladder  and  to  form  the  nucleus  of  a 
stone.  The  sudden  appearance  of  a  large  amount  of  pus  in  the 
urine  together  with  the  symptoms  of  acute  cystitis  should  lead  to 
the  suspicion  that  a  tubo-ovarian  or  other  pelvic  abscess  has  dis- 
charged into  the  bladder.  If  the  patient  has  been  under  previous 
observation  and  an  abscess  has  been  diagnosed,  palpation  will 
show  it  to  be  collapsed.  Cystoscopy  is  the  only  sure  means  of 
making  a  diagnosis  of  fistula  in  such  cases,  the  opening  being 
found  and  probed  by  sight.  Bimanual  palpation  shows  the  pres- 
ence of  an  inflammatory  mass  adjacent  to  the  bladder  wall  in  this 
class  of  fistula?. 


NEW  GROWTHS  OF  THE  BLADDER 

Neoplasms  of  the  bladder  are  either  secondary  to  a  malignant 
growth  in  an  adjacent  organ, — perhaps  by  direct  extension,  as  in 
the  case  of  carcinoma  of  the  cervix,  or  perhaps  by  metastasis  from 
cancer  of  a  distant  organ, — or  they  are  primary  in  the  bladder 
itself.  Primary  tumors  of  the  bladder  are  relatively  rare,  being 
from  three  to  five  times  less  frequent  in  women  than  in  men.  They 
are  most  often  observed  between  the  ages  of  forty  and  sixty,  but 
may  occur  at  any  age,  though  of  very  unusual  occurrence  before 
thirty.  Nothing  is  known  of  their  causation.  .  They  are  to  be 
classed  as  benign  and  malignant.  The  benign  arc:  papilloma, 
fibroma,  myoma,  and  adenoma;  the  malignant  are:  malignant 
papilloma,  carcinoma,  and  sarcoma.  The  tumors  may  spring  from 


NEW  GROWTHS  OF  THE  BLADDER  481 

the  mucosa,  from  the  submucosa,  or  from  the  muscular  layer, 
and  they  are  more  apt  to  be  situated  on  the  base  or  on  the  posterior 
wall,  and  show  a  tendency  to  be  single  rather  than  multiple.  E. 
Hurry  Fenwick,  whose  experience  with  bladder  tumors  has  been 
extensive,  says: — " Broadly  speaking,  the  cystoscopist  will  en- 
counter two  well-marked  varieties  of  vesical  tumors:  the  villus- 
covered  and  the  bald.  Those  clothed  with  villous  processes  may 
be  benign  or  they  may  be  malignant,  but  the  smooth-surfaced 
groups  are  almost  always  malignant,  more  especially  if  they  occur 
after  the  age  of  forty-five." 

Symptoms. — The  symptoms  of  bladder  tumors  in  general  are, 
sudden  stoppage  of  the  urine  with  resulting  pain  (in  the  case  of 
pedunculated  growths),  and  intermittent  hemorrhage  at  the  end 
of  urination,  or  mixed  with  the  urine.  Renal  pain  in  the  kidney 
whose  ureteric  orifice  is  nearer  the  tumor  in  the  bladder  is  a  not 
uncommon  symptom.  Spontaneous  coagulation  of  the  urine  in  a 
vessel  (fibrinuria)  due  to  the  excess  of  fibrin  discharged  with  the 
blood  in  the  urine  has  been  observed  only  in  the  case  of  bladder 
tumors.  Cystitis  is  a  late  manifestation.  Frequent  micturition  is 
common,  especially  if  the  base  of  the  bladder  and  the  trigone  are 
affected. 

Diagnosis. — The  diagnosis  depends  on  the  history,  on  palpation, 
on  the  cystoscopic  appearances,  and  on  the  microscopic  examination 
of  shreds  in  the  urine  and  tissue  removed  from  the  bladder.  Malig- 
nancy is  distinguished  from  benignity  only  by  the  greater  pre- 
ponderance of  pain  and  induration  of  the  tissues  in  the  former. 
Certain  distinguishing  characteristic  features  will  be  taken  up 
with  each  disease.  Lincoln  Davis  (Annals  of  Surgery,  April,  1906), 
from  an  analysis  of  forty-five  cases  occurring  in  the  Massachusetts 
General  Hospital,  thinks  that  the  important  diagnostic  feature  of 
malignancy  of  bladder  tumors  is  the  infiltration  of  the  underlying 
bladder  wall,  and  that  the  recurrence  of  epithelial  tumors  does 
not  mean  necessarily  that  they  are  malignant.  The  electric  cys- 
toscope  with  water-distended  bladder  is  especially  well  adapted  to 
the  inspection  of  bladder  tumors  and  very  beautiful  pictures  are 
obtained  of  the  villi  of  a  papillomatous  growth  floating  in  the 
bladder  fluid  like  the  tentacles  of  a  sea  anemone. 

31 


482  DISEASES  OF  THE  BLADDER 


BENIGN  TUMORS 

Papilloma. — Papillomata  arc  the  most  common  of  all  vesical 
tumors.  The  name  papilloma  is  given  to  pedunculated  tufted 
tumors,  but  the  shape  docs  not  necessarily  indicate  their  patho- 
logical structure,  so  that  it  happens  that  papilloma,  although  com- 
monly made  up  of  submucous  connective  tissue — a  fibroma,  and 
therefore  benign — may  be  an  outgrowth  of  the  epithelial  tissue 
of  the  mucosa  and  therefore  malignant.  The  benign  papilloma 
is  made  up  of  a  framework  of  connective  tissue  richly  supplied 


FIG.  190. — Papilloma  (Fibroepithelioma)  of  the  Bladder.     (Knorr.) 

with  blood-vessels  and  covered  with  pavement  bladder  epithelium. 
It  has  a  branching,  villous  appearance,  the  villi  arc  often  of  extreme 
thinness  and  resemble  chorionic  villi,  or  they  may  be  short  and 
stunted  and  some  may  be  covered  with  white  phosphatic  deposits. 
The  villi  may  be  so  short  that  a  papillomatous  growth  may  appear 
through  the  cystoscope  to  be  smooth  on  first  inspection ;  in  this  event 
it  looks  white,  differing  from  the  smooth  reddish  or  reddish-white 
surface  of  an  epithelioma.  These  growths  are  generally  single  in 
their  early  stages  and  the  base  never  reaches  downward  beyond  the 
submucosa.  They  vary  in  size  from  a  pea  to  a  hen's  egg,  the  latter 
being  rare,  and  are  more  commonly  found  in  the  neighborhood  of 
the  ureteric  orifice,  outside  the  trigonc.  The  mouth  of  the  ureter 


NEW  GROWTHS  OF  THE  BLADDER  483 

nearer  the  tumor  is  reddened  and  is  converted  into  a  furrow  instead 
of  being  a  little  slit.  The  surrounding  mucosa  of  the  bladder  is 
generally  reddened  and  swollen.  If  the  pedicle  is  long  the  growth 
will  float  about  and  is  likely  to  plug  the  internal  orifice  of  the 
urethra,  and  therefore  cause  retention.  The  more  sessile  the 
tumor  and  the  further  it  is  situated  toward  the  posterior  wall,  the 
less  likely  is  this  result  to  occur. 

The  first  symptom  of  papilloma  is  blood  at  the  end  of  micturition ; 
later  the  amount  of  blood  lost  may  be  alarming.  An  ache  in  the 
kidney  on  the  side  of  the  body  on  which  the  tumor  is  situated  is  a 
symptom  of  the  advanced  stages  when  the  growth  has  increased 
in  size.  This  ache  is  thought  to  be  due  to  ascending  infection  of  the 
ureter  and  kidney,  with  or  without  hydronephrosis.  Impeded 
urination  occurs  if  the  tumor  obstructs  the  urethral  orifice,  and 
cystitis  may  be  a  late  result.  The  diagnosis  rests  on  these  symp- 
toms, on  the  finding  of  a  tumor  by  vaginal  palpation  of  the  bladder 
base,  and  on  the  cystoscopic  appearances  as  described  above. 
The  microscopic  examination  of  pieces  of  tissue  passed  in  the  urine 
or  removed  by  the  alligator  forceps  will  alone  settle  the  diagnosis 
of  the  sort  of  tumor  present. 

Fibroma  and  Myoma. — These  benign  tumors  are  of  rare  occur- 
rence. A  fibroma  or  fibroid  polyp  is  made  up  of  connective  tissue, 
it  is  usually  pedunculated  and  has  a  smooth  or  slightly  lobulated 
surface.  Its  pedicle  is  well  vascularized,  but  the  tumor  itself  is  not. 
The  latter  fact  may  be  the  reason  that  these  tumors  are  apt  to 
undergo  myxomatous  degeneration.  Only  a  few  cases  of  myoma 
of  the  bladder  have  been  described.  They  begin  in  the  muscular 
coat  and  develop  into  the  cavity  of  the  bladder  either  as  a  sessile 
or  as  a  pedunculated  growth.  In  one  reported  case  the  myoma 
was  on  the  outside  of  the  bladder. 

Adenoma. — This  is  a  rare  benign  epithelial  tumor  of  the  glandular 
type ;  it  is  sessile  or  stalked,  and  has  a  smooth,  lobulated,  or  villous 
surface.  The  sessile  growth,  as  in  the  case  of  the  fibroid  polyp, 
can  be  enucleated  easily  from  the  bladder  wall. 

MALIGNANT  TUMORS 

Carcinoma. — There  are  two  sorts  of  primary  cancer  of  the  bladder, 
one  squamous-celled,  and  the  other  cylindrical-celled.  The  disease 
begins  as  a  small  nodule  either  of  the  cncephaloid,  scirrhus,  or 


484  DISEASES  OF  THE  BLADDER 

colloid  type,  and  has  a  tendency  to  remain  localized  in  the  bladder 
for  a  long  time.  Later,  multiple  tumors  are  found,  and  ulceration, 
cystic  degeneration,  and  gangrene  occur.  The  bladder  wall  sur- 
rounding and  under  the  tumor  is  indurated.  The  surface  of  the 
tumor  may  be  covered  with  villi,  which  are  more  vascular  than 
in  the  case  of  the  benign  growths;  the  growth  is  apt  to  be  sessile. 
The  disease  extends  from  the  base  of  the  bladder,  its  usual  situa- 
tion, to  the  ureters,  often  closing  one  or  both  orifices  and  causing 
renal  disease  and  it  either  forms  a  tumor  in  the  bladder  or  infiltrates 
the  bladder  wall  and  the  surrounding  tissues.  The  symptoms 
are  the  same  as  in  papilloma  and  the  diagnosis  is  made  in  the  same 
manner.  Much  induration  of  the  tissues  in  the  bladder  base 
points  toward  carcinoma  and  constant  pain  in  the  region  of  the  blad- 
der, and  frequency  of  micturition,  are  characteristic  symptoms. 
Cystitis,  with  pain  in  other  regions,  as  in  the  back  and  thigh,  and 
emaciation,  are  late  manifestations.  The  exact  diagnosis  is  made 
by  the  microscopic  examination  of  a  portion  of  tissue  either  from 
the  urine  or  removed  from  the  bladder  through  the  cystoscope. 

Sarcoma. — Primary  sarcoma  of  the  bladder  is  extremely  rare, 
although  more  frequent  than  in  men.  It  may  occur  at  any  age. 
The  tumors  are  of  rapid  growth,  usually  multiple.  They  are 
sessile  and  tend  to  grow  out  through  the  urethra.  They  are  red  or 
blackish  in  color  and  have  a  smooth  surface. 


FUNCTIONAL  DISTURBANCES  OF  THE  BLADDER 

As  has  been  pointed  out  already,  any  disease  that  interferes  with 
the  normal  physiology  of  the  trigone  and  neck  of  the  bladder  is 
apt  to  cause  bladder  symptoms,  as,  for  instance,  hypcremia  of 
the  trigone  or  trigonitis,  and  dislocation  of  the  neck  of  the  bladder. 
In  these  days  of  cystoscopy  we  find  many  instances  of  frequency  of 
urination  where  the  only  discoverable  abnormality  is  injection  of 
the  mucosa  of  the  trigone.  A  concentrated  urine  from  lack  of 
sufficient  ingested  fluids,  urine  containing  an  excess  of  uric  acid, 
crystals  of  oxalic  acid,  or  turpentine,  cantharides  or  other  irritating 
substances,  is  a  cause  often  of  frequency  of  micturition.  So  also 
may  be  a  urethra  of  caliber  insufficient  to  drain  the  bladder  freely 
and  speedily. 


FUNCTIONAL   DISTURBANCES  OF  THE   BLADDER        485 

Irritability  of  the  bladder  has  been  the  term  that  has  in  the  past 
cloaked  a  multitude  of  sins  of  omission  in  diagnosis.  In  hysteria 
the  secretion  of  large  quantities  of  limpid  urine  with  consequent 
frequency  of  micturition  alternates  with  scanty  high-colored  urine. 
Spasm  of  the  detrusor  fibers  of  the  bladder  with  the  involuntary 
discharge  of  urine  occurs  sometimes  in  this  disease,  and  hysterical 
retention  is  frequent. 

When  there  is  spasm  of  the  neck  of  the  bladder  in  hysteria  there 
may  be  great  difficulty  in  starting  urination.  Incontinence  may 
occur  with  an  attack  of  epilepsy.  In  the  case  of  locomotor  ataxia 
there  is  lack  of  control  over  the  bladder,  beginning  as  a  delay  in 
starting  micturition;  after  the  flow  has  begun  it  stops  suddenly, 
then  starts  again,  and  when  the  bladder  seems  to  be  emptied  urine 
is  passed  into  the  clothes. 

In  this  disease  there  may  be  also  partial  or  complete  retention 
with  incontinence  from  overdistention,  or  vesical  tenesmus. 

Retention  and  incontinence  occur  in  Pott's  disease  and  in  in- 
juries of  the  brain  and  spinal  cord,  and  also  in  general  paralysis  of 
the  insane.  Retention  is  noted  as  a  constant  symptom  in  multiple 
sclerosis. 

Where  the  passing  of  large  quantities  of  urine  is  due  to  mental 
influences,  as  in  the  case  of  apprehension  and  worry,  and  not  to 
organic  nervous  disease,  the  frequency  of  micturition  is  limited  to 
the  day-time,  for  as  a  rule  such  a  patient  sleeps  all  night  without 
rising  to  empty  her  bladder. 

Incontinence  of  urine  is  of  two  sorts,  that  which  occurs  in  over- 
distention of  the  bladder,  the  drop-by-drop  kind,  with  incessant 
dribbling,  and  the  incontinence  in  the  form  of  intermittent  evac- 
uations of  large  quantities  of  urine.  The  first  kind  is  due  to  any 
cause  which  distends  the  bladder  with  urine,  the  cause  being  found 
among  the  functional  and  organic  diseases  of  the  bladder;  the 
second  is  supposed  to  be  due  to  faulty  innervation  of  that  organ. 
The  latter  kind  is  most  frequent  in  children.  Many  of  these  children 
are  quite  normal  as  to  their  urinary  functions  during  the  day  and 
the  incontinence  is  nocturnal  only;  others,  a  smaller  proportion,  not 
only  wet  their  beds  at  night,  but  experience  pressing  calls  to  urinate 
(luring  the  day,  and  if  not  attended  to  at  once,  wet  their  clothes. 
(See  Enuresis,  Chapter  XX VIII.,  page  578.) 


CHAPTER  XXV 
THE  DIAGNOSIS  OF  DISEASES  OF  THE  URETERS 

Anomalies,  p.  486:  Double  ureter,  p.  486.  Abnormal  situation  of 
ureteral  orifice,  p.  486.  Cystic  dilatation  of  an  occluded  ureter,  p.  487. 

Ureteritis,  p.  488. 

Stricture  of  the  ureter,  p.  489. 

Ureteral  calculus,  p.  490. 

Prolapse  of  the  ureteral  mucosa  into  the  bladder,  p.  491. 

Ureteral  Fistula?,  p.  492:  Uretero-uterine,  p.  492.  Uretero-vaginal,  p. 
492.  Uretero-vesical,  p.  492.  Uretero-intestinal,  p.  493. 

New  growths  of  the  ureter,  p.  493. 

THE  anatomy  and  physiology  of  the  ureters  and  the  methods  of 
examination  will  be  found  described  in  Chapter  VIII.,  page  104. 

ANOMALIES 

Anomalies  of  the  ureter  are  rare.  One  ureter  has  been  found 
wanting,  just  as  one  kidney  is  sometimes  absent.  It  is  the  rule 
that  extreme  degrees  of  ureteral  malformations  are  associated  with 
non-viable  fetuses. 

Double  ureter  is  the  anomaly  most  frequently  observed.  The 
duplication  may  start  at  the  kidney  from  two  separate  pelves  and 
then  unite  at  some  point  below  to  form  one  canal  to  the  bladder, 
or  it  may  continue  double  and  enter  the  bladder  by  two  orifices,  one 
behind  the  other.  Cases  are  reported  in  which  a  double  ureter  was 
found  on  each  side  in  the  same  patient.  The  anomaly  has  little 
if  any  clinical  importance  and  is  discovered  in  the  course  of  cystos- 
copy,  during  operations  on  the  kidney,  or  at  autopsies. 

Abnormal  Situation  of  Ureteral  Orifice. — The  ureteral  orifice  has 
been  found  in  one  of  the  following  situations:  the  vagina,  the 
urethra,  near  the  external  meatus,  and  under  the  prepuce  of  the 
clitoris. 

The  patient  suffers  from  persistent  leakage  of  urine,  but  at  the 
same  time  empties  her  bladder  at  regular  intervals.  The  importance 
of  finding  out  whether  the  abnormally  placed  ureteral  orifice  is 
the  only  outlet  of  a  ureter  or  a  supernumerary  orifice  is  apparent. 

480 


ANOMALIES  487 

The  history  of  incontinence  existing  from  birth  in  a  virgin  is  a 
presumption  in  favor  of  abnormal  congenital  implantation,  al- 
though the  other  causes  of  incontinence  of  urine  (see  Chapter  X., 
page  154)  must  be  investigated.  If,  on  the  other  hand,  the  inconti- 
nence dates  from  a  difficult  labor,  or  the  patient  has  been  subjected 
to  some  operative  interference,  the  probability  is  that  an  abnormal 
situation  of  a  ureteral  orifice  has  been  artificially  induced.  If  the 
orifice  should  be  under  the  prepuce  of  the  clitoris,  drying  the  vulva, 
with  cotton  and  watching  it  will  soon  determine  the  source  of  the 
urine.  If  the  orifice  is  in  the  urethra  the  urethra  must  be  inspected 
through  its  entire  length  most  carefully  with  a  cystoscope  in  order 
to  find  the  opening.  If  in  the  vagina,  the  vagina  is  dried  with 
cotton  after  a  speculum  has  been  introduced,  and  search  is  made 
for  the  ureteral  orifice.  By  placing  a  light  packing  of  dry  absorbent 
cotton  in  the  vagina  and  removing  it,  one  may  fix  approximately 
the  situation  of  the  opening  by  the  situation  of  the  spot  of  urine 
on  the  cotton.  Does  the  wet  cotton  smell  of  urine?  A  fine  probe 
may  be  used  as  a  searcher.  The  bladder  is  injected  with  milk  and 
water  or  aniline-blue  solution  to  rule  out  this  viscus  as  a  source  of 
the  escaping  urine.  If  none  of  the  colored  fluid  escapes  into  the 
vagina  the  opening  found  in  the  vagina  is  a  ureteral  orifice.  Cys- 
toscopy  is  now  performed  and  search  made  for  both  ureteral  orifices 
in  the  bladder.  If  only  one  is  found  the  inference  is  that  the  opening 
in  the  vagina  is  of  the  opposite  ureter.  A  sterile  ureteral  catheter 
is  passed  into  it  and  the  catheter  palpated  by  rectal  examination. 
If  two  orifices  are  found  in  the  bladder  a  ureteral  catheter  is  passed 
into  each  and  an  attempt  made  to  touch  one  of  them  with  the  tip 
of  a  probe  introduced  into  the  orifice  in  the  vagina,  thus  determining 
a  supernumerary  orifice,  and  also  on  which  side  of  the  body,  and 
with  which  kidney  it  is  connected. 

Cystic  dilatation  of  an  occluded  ureter  has  been  reported.  In  this 
anomaly  the  lower  end  of  the  ureter  has  failed  to  communicate 
with  the  bladder  or  with  any  other  part  of  the  genital  tract.  The 
reported  cases  have  been  in  adults.  In  one  instance  the  ureter 
ended  in  a  cyst  that  was  mistaken  for  a  cyst  of  the  vagina.  Uterine 
anomalies  care  apt  to  accompany  the  blind  ending  of  a  ureter; 
sometimes  the  ureter  may  end  without  dilatation.  In  either  event 
the  corresponding  kidney  is  the  seat  of  hydronephrosis  or  it  is 
atrophied. 


488  DISEASES  OF  THE  URETERS 

In  all  urcteral  diseases  as  well  as  in  cases  of  suspected  nephritis 
the  physician  must  watch  each  ureteral  orifice  separately  and 
note  the  character  of  urine  issuing  from  it,  whether  clear,  turbid, 
or  bloody,  the  force  with  which  the  urine  is  ejected,  and  the  rate  of 
frequency  of  the  spurts.  It  will  be  found  that  in  the  case  of  a  diseased 
kidney  of  diminished  functional  capacity  the  rate  of  spurting  from 
the  ureteral  orifice  will  be  much  diminished — perhaps  only  once  in 
two  minutes — while  the  orifice  from  the  sound  kidney  spurts 
urine  every  twenty  seconds.  Where  the  kidney  is  atrophic  there 
may  be  no  discharge  of  urine  from  the  ureter  on  that  side. 

URETERITIS 

Inflammation  of  the  ureter  arises  from  extension  of  inflammation 
downward  from  the  kidney,  upward  from  the  bladder,  from  some 
cause  in  the  ureter  itself — as  from  a  calculus  in  the  ureter — or 
from  inflammation  in  the  cellular  tissue  surrounding  the  ureter, — 
pcriureteritis,  so-called.  As  a  rule  the  disease  is  due  to  the  tubercle 
bacillus,  to  the  gonococcus,  or  to  the  colon  bacillus,  except  in  the 
cases  of  stone  in  the  ureter;  and  ureteritis  is  secondary  to  disease 
of  the  kidney  or  bladder,  therefore  its  symptoms  are  often  over- 
shadowed by  the  symptoms  of  those  diseases.  Pain  in  one  groin 
extending  up  to  the  kidney  on  the  same  side,  with  frequent  and 
painful  micturition  and  pus  in  the  urine,  are  the  symptoms  of 
ureteritis.  The  diagnosis  is  established  by  the  symptoms  and  by 
the  physical  examination.  Palpation  of  the  base  of  the  bladder  and 
the  lateral  vaginal  fornix  will  detect  a  tender,  thickened  cord  cours- 
ing toward  the  posterior  pelvis.  This  cord  may  be  traced  a  little 
farther  by  rectal  palpation.  An  acutely  inflamed  ureter  is  very 
sensitive.  The  abdominal  course  of  the  ureter  may  be  palpated 
in  patients  who  are  not  too  fat  by  finding  the  promontory  of  the 
sacrum,  and  rolling  the  abdominal  wall  over  a  point  situated  two 
fingers'  breadth  to  one  side,  for  at  this  point  the  ureter  crosses  the 
brim  of  the  true  pelvis.  If  the  ureter  is  inflamed  at  this  point  the 
patient  will  experience  pain  when  it  is  pressed  against  the  under- 
lying bone. 

Through  the  cystoscopc  the  orifice  of  an  inflamed  ureter  will 
generally  be  found  in  a  puffy  and  swollen  inons  situated  in  an  area 
of  injected  mucosa,  and  cloudy  urine  may  be  seen  to  issue  from  it. 


STRICTURE  489 


STRICTURE  OF  THE  URETER 

Stricture  or  obstruction  of  the  caliber  of  the  ureter  is  much 
more  common  in  women  than  in  men.  It  may  be  due  to  (a)  pressure 
from  without,  to  (6)  a  foreign  body  in  the  canal,  or  to  (c)  localized 
contractions  or  narrowing  of  the  lumen  caused  by  inflammatory 
action  or  to  valve  formation  hi  the  walls  of  the  ureter  itself,  a. 
Some  of  the  causes  of  obstruction  of  the  ureter  from  without  are: — 
Ovarian  and  uterine  tumors,  cancerous  infiltration  of  the  broad 
ligaments,  thickened  bladder  walls,  and  tumors  of  the  bladder. 
b.  The  bodies  that  may  obstruct  the  canal  of  the  ureter  are:  a 
calculus,  a  blood  clot,  or  an  echinococcus  cyst.  c.  The  affections 
of  the  ureteral  walls  are :  ureteritis,  valve  formation  in  the  ureteral 
wall,  cancer  of  the  ureter,  and  gumma  of  the  ureter. 

The  situation  of  obstruction  is  almost  always  in  the  pelvic  portion 
of  the  ureter,  rarely  in  the  upper  end  near  the  pelvis  of  the  kidney. 
Certain  diseases  of  those  mentioned  are  apt  to  cause  obstruction 
of  both  ureters.  They  are:  cancer  of  the  cervix  extending  into 
the  bases  of  the  broad  ligaments,  thickened  bladder  walls  from 
any  cause,  and  subperitoneal  fibroid  tumors.  In  other  cases  the 
obstruction  is  apt  to  be  unilateral. 

The  symptoms  depend  on  whether  the  obstruction  is  of  sudden  or 
of  gradual  occurrence.  In  the  former  case  there  is  pain  hi  the  course 
of  the  ureter;  in  the  latter,  there  may  be  no  symptoms  at  all.  If 
the  obstruction  depends  on  ureteritis  the  symptoms  will  be  those 
of  ureteritis.  Persistent  pain  in  the  course  of  the  ureter  and  pus 
in  the  urine  should  lead  to  an  investigation  of  the  cause.  The 
diagnosis  is  made  by  palpating  the  ureter  by  vagina,  by  rectum,  and 
at  the  pelvic  brim,  as  described  in  the  diagnosis  of  ureteritis.  Search 
should  be  made  for  tumors  of  the  pelvis,  or  for  exudates  which 
may  press  on  the  ureter,  remembering  that  it  is  in  the  pelvis  that 
obstruction  generally  occurs. 

Cathetorization  of  the  ureter  through  the  cystoscope  will  show, 
first,  that  the  catheter  meets  a  sudden  check,  or  after  meeting  a  less 
pronounced  obstruction  it  may  pass  by  a  narrowed  part  of  the 
ureter,  whereupon  there  is  an  immediate  flow  of  an  ounce  or  more 
of  urine.  Perhaps  the  catheter  will  be  seized  at  the  stricture  and 
resist  withdrawal. 


490  DISEASES  OF  THE  URETERS 

In  introducing  a  metal  catheter  into  the  ureter  for  searching 
purposes  it  is  well  to  have  the  patient  in  the  dorsal  position,  so  that 
after  the  catheter  is  in  place  its  further  course  may  be  guided  by 
the  finger  in  the  rectum.  In  using  the  gum-elastic  or  renal  catheter 
the  examination  is  begun  with  the  patient  in  the  knee-chest  position. 
After  the  catheter  has  been  introduced  the  patient  is  lowered  to 
the  dorsal  position  and  a  bladder  catheter  passed  to  let  the  air  out 
of  the  bladder.  The  point  where  the  stricture  is  situated  is  noted 
by  withdrawing  the  catheter  until  the  eye  has  become  engaged 
in  the  stricture.  At  this  point  the  flow  of  urine  stops.  Measure 
from  the  outer  end  of  the  catheter  to  the  meatus  urinarius.  After 
the  catheter  is  out  the  difference  between  this  measurement  and 
the  total  length  of  the  catheter  is  the  distance  of  the  upper  part  of 
the  stricture  from  the  meatus.  To  determine  the  distance  of  the 
stricture  from  the  bladder,  subtract  from  the  last  measurement 
the  distance  from  the  meatus  to  the  uretcral  orifice,  as  measured 
by  the  ureteral  searcher  passed  through  the  cystoscope. 

Graduated  whalebone  bougies  have  been  used  to  determine  the 
situation  and  size  of  strictures  of  the  ureter  by  various  investigators. 
I  have  had  the  best  results  with  the  Kelly  gum-elastic  renal  catheters 
which  contain  stylets. 


URETERAL  CALCULUS 

A  calculus  is  much  more  often  found  in  the  renal  pelvis  or  in  the 
bladder  than  in  the  ureter.  If  the  calculus  has  been  lodged  in  the 
ureter  for  any  considerable  length  of  time  it  is  apt  to  have  a  spindle 
shape.  The  calculus  forms  in  the  pelvis  of  the  kidney  and  works 
down  into  the  ureter;  it  may  be  about  an  inch  (2.5  centimeters) 
long  and  a  quarter  of  an  inch  (5  millimeters)  in  diameter,  but 
smaller  ones  are  most  often  seen.  A  calculus  five  inches  (12.5  centi- 
meters) long  has  been  observed.  Calculi  generally  lodge  just 
below  the  pelvis  of  the  kidney,  at  the  pelvic  brim,  and  in  the  pelvic 
floor.  Severe  pain  in  the  course  of  the  ureter, — often  accompanied 
by  chills  and  rigors,  rapid  pulse,  and  prostration,— is  characteristic 
of  the  lodgment  of  a  stone  in  the  ureter.  Paroxysms  of  pain 
come  on  intermittently  at  variable  intervals  as  long  as  the  stone  is 
in  the  ureter.  If  the  stone  moves  downward  by  irregular  gradations 


PROLAPSE    OF    THE    URETERAL    MUCOSA  491 

its  movement  may  be  traced  by  the  appearance  of  blood  in  the 
urine.  The  stone,  damming  up  the  urine,  causes  hydroureter  and 
by  forming  a  ball  valve  in  some  cases  permits  the  intermittent 
discharge  of  large  quantities  of  urine.  In  the  course  of  time  the 
kidney  is  damaged  by  the  back  pressure  of  urine,  by  infection,  or 
by  both. 

The  diagnosis  is  established  by  the  symptoms,  by  palpation,  and 
by  catheterizing  the  ureters.  A  stone  in  the  pelvic  floor  may  be 
palpated  by  vaginal  and  rectal  palpation  and  at  the  pelvic  brim 
by  abdominal  palpation.  In  the  upper  part  of  the  true  pelvis  a 
stone  may  be  felt  by  high  rectal  palpation.  Through  the  cystoscope 
a  stone  may  be  seen  projecting  from  the  ureteral  orifice  or  pushing- 
the  mons  into  the  bladder;  if  not,  it  may  be  touched  with  the 
metallic  ureteral  catheter  introduced  in  the  ureter.  To  detect  a 
stone  high  up  in  the  ureter  Dr.  Kelly  uses  a  flexible  renal  catheter 
tipped  with  a  light  coating  of  dental  wax,  noting,  after  the  catheter 
has  been  withdrawn,  the  scratch  marks  made  by  the  stone  on  the 
wax. 

The  X-rays  may  be  used  to  detect  the  presence  and  situation  of  a 
ureteral  calculus,  a  competent  radiologist  being  employed  to 
obtain  a  photograph,  and  also,  if  the  calculus  is  in  the  upper  portion 
of  the  ureter,  an  exploratory  incision  may  be  made  either  through 
the  abdomen  in  the  linea  semilunaris,  or  extraperitoneally  in  the 
lumbar  region,  as  for  nephrectomy.  If  an  incision  is  made  plans 
should  be  perfected  beforehand  to  proceed  with  an  operation  for 
the  removal  of  a  stone  should  palpation  through  the  wound  reveal 
its  presence. 


PROLAPSE  OF  THE  URETERAL  MUCOSA  INTO  THE  BLADDER 

Prolapse  of  the  ureteral  mucosa  into  the  bladder  has  been  found 
rarely  in  children  and  is  probably  congenital.  It  is  thought  to 
depend  on  stricture  of  the  ureteral  orifice  causing  the  lower  end 
of  the  ureter  to  project  into  the  bladder  in  the  form  of  a  cystic 
tumor,  the  obstructed  ureteral  orifice  being  at  some  point  on  the 
circumference  of  the  tumor.  Cases  of  acquired  prolapse  of  this 
sort  have  boon  reported  and  it  is  likely  that  the  disease  occurring 
in  children  has  the  same  mechanism  of  causation. 


492  DISEASES  OF  THE  URETERS 


URETERAL  FISTULA 

A  urctcral  fistula  is  an  abnormal  opening  between  the  canal  of 
the  ureter  and  the  surface  of  the  body,  or  some  part  of  the  genital 
or  alimentary  tract.  Ureteral  fistula;  are  congenital,  as  pointed 
out  in  the  consideration  of  anomalies,  page  486,  or  they  are  produced 
by  trauma, — most  commonly  as  a  result  of  a  difficult  labor, — from 
injuries  in  the  course  of  operations  on  the  pelvic  contents  or  on 
abdominal  tumors,  or  they  are  caused  by  ulceration.  They  involve 
generally  the  pelvic  portion  of  the  ureter.  Difficult  labor  may 
cause  sloughing  of  the  uterus  or  vagina  and  the  ureteral  wall, 
leaving  a  permanent  uretero-uterine  or  uretero-vaginal  fistula.  The 
ureters  have  been  cut  in  the  course  of  hysterectomy  many  times,— 
sometimes  when  the  cause  of  death  has  been  set  down  as  exhaustion 
or  peritonitis.  In  cases  where  the  patient  has  survived,  the  urine 
finds  its  escape  through  the  drainage  tract  either  in  the  abdominal 
wall  or  in  the  vagina.  In  one  of  my  cases  the  ureter  discharged 
through  the  canal  of  the  cervix  uteri,  a  supravaginal  amputation 
having  been  performed  for  a  large  fibroid.  The  opening  healed 
spontaneously  in  the  course  of  a  few  weeks.  This  is  the  issue  in 
many  cases.  Sometimes,  however,  the  fistula  is  permanent. 

A  ureteral  stone  has  been  known  to  ulcerate  through  the  walls 
of  the  ureter  and  bladder,  finding  its  way  into  the  latter  viscus  and 
forming  a  uretero-vesical  fistula. 

In  making  a  diagnosis  of  ureteral  fistula  it  is  to  be  remembered 
that  in  the  congenital  forms  the  opening  of  the  ureter  is  generally 
situated  low  down  near  the  external  genital  organs,  i.e.,  under  the 
prepuce  of  the  clitoris,  near  the  meatus  urinarius,  or  in  the  lower 
vagina;  in  the  acquired  forms,  on  the  other  hand,  the  opening  is 
more  apt  to  be  higher  up  near  the  base  of  the  bladder,  or  in  the 
vault  of  the  vagina.  The  congenital  fistula;  have  a  history  of  loss 
of  urine  since  childhood,  whereas  the  acquired  date  from  some 
operation,  a  difficult  labor,  or  from  some  definite  date.  If  only  one 
ureter  is  involved  in  the  fistula,  the  usual  happening,  the  patient 
passes  urine  by  the  urethra  as  well  as  experiencing  the  discomfort 
of  more  or  less  constant  leakage.  If  the  fistula  is  into  a  vagina 
closed  by  a  tight  hymen  the  loss  of  urine  may  occur  only  when 
the  patient  is  in  the  erect  posture. 


NEW  GROWTHS  OF  THE  URETER  493 

The  bladder  is  injected  with  aniline  blue  and  water,  or  with  milk 
and  water,  and  if  there  is  a  fistula  involving  the  bladder  and  the 
uterus,  or  bladder  and  vagina,  the  escape  of  the  colored  fluid  will 
be  noted.  If  there  is  a  fistula  in  the  lower  pelvic  course  of  the 
ureter  a  metal  ureteral  catheter  passed  into  this  ureter  will  go  an  inch 
or  two  but  not  beyond  the  situation  of  the  fistula,  whereas  in  the 
sound  ureter  it  may  be  pushed  gently  well  up  into  the  pelvis,  some 
three  inches. 

Uretero-intestinal  fistula  is  apt  to  be  the  sequel  of  an  operation, 
but  may  be  congenital.  If  the  ureter  opens  into  the  intestine 
infection  commonly  passes  up  the  ureter  to  the  kidney.  This 
has  been  the  result  of  artificially  turning  the  ureters  into  the  rectum 
because  in  this  case  there  is  no  valve  at  the  orifice  to  protect  the 
ureter.  The  urine  is  generally  irritating  to  the  rectal  mucosa  and 
the  patient  when  constipated  feels  a  desire  for  defecation  and 
passes  urine  without  feces  per  anum.  Cystoscopy  shows  only  one 
ureteral  orifice,  or  one  orifice  transmitting  urine  and  the  other 
functionless. 

NEW  GROWTHS  OF  THE  URETER 

Primary  tumors  of  the  ureter  are  rare.  E.  Garceau  ("  Renal  and 
Ureteral  Tumors,"  1909)  mentions  fourteen  cases  of  strictly  localized 
primary  ureteral  tumors  which  he  has  analyzed,  ureteral  calculus 
being  associated  with  two  of  these.  The  more  usual  forms  are 
epithelial  growths  occurring  in  the  varieties  of  papilloma,  and 
papillary  and  non-papillary  epithelioma. 

One  or  two  cases  of  mesodermal  growths  have  been  recorded. 
Ureteral  tumors  are  practically  all  malignant.  They  originate 
generally  in  the  upper  ureter  or  in  the  pelvis  of  the  kidney.  Their 
symptoms  are  pain,  hemorrhage,  and  the  presence  of  a  tumor,  and 
the  diagnosis  has  been  made  in  only  a  very  few  cases  without 
operation.  The  diagnosis  may  be  made,  however,  in  the  presence 
of  hematuria  by  isolating  characteristic  cells  of  the  growth  from 
the  urine  drawn  from  the  pelvis  of  the  kidney  by  the  renal  catheter. 


CHAPTER  XXVI 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  RECTUM 

Anomalies,  p.  494:  1.  Arrest  or  irregular  development  of  the  hind  gut, 
p.  490;  Iniperf orate  rectum,  p.  496;  Imperforate  rectum  with  outlet  into 
the  urethra  or  bladder,  p.  490;  Imperforate  rectum  with  outlet  into  the 
vagina,  p.  497.  2.  Arrest  or  irregular  development  of  the  proctodeum,  p. 
497;  Imperforate  anus,  p.  497;  Imperforate  anus  with  anal  canal  ending 
in  the  vulva,  p.  497;  Anus  well-formed,  anal  canal  ending  above  in  a  cul-de- 
sac,  p.  497;  Abnormally  small  anus,  p.  498. 

Hemorrhoids  or  Piles:  Frequency  and  etiology,  p.  498.  External  hemor- 
rhoids, p.  500.  Internal  hemorrhoids,  p.  501. 

Fissure  in  Ano,  p.  503:  Symptoms,  p.  503.  Diagnosis,  p.  504.  Differ- 
ential diagnosis,  p.  50.3. 

Inflammation  of  the  Rectum,  Proctitis,  p.  505:  1.  Simple  proctitis,  p. 
506;  Acute  catarrhal  proctitis,  p.  506;  Chronic  catarrhal  proctitis,  p.  507; 
Atrophic  proctitis,  p.  507;  Hypertrophic  proctitis,  p.  508.  2.  Specific 
proctitis,  p.  510;  Gonorrheal  proctitis,  p.  510;  Syphilis  of  the  rectum  and 
anus,  p.  510;  Congenital  syphilis,  p.  510;  Chancre,  p.  511;  Mucous  patches, 
p.  511;  Ulcerations,  p.  512;  Gummata,  p.  512;  Syphilitic  stricture,  p.  512; 
Chancroids  of  the  anus  and  rectum,  p.  512;  Tuberculosis  of  the  anus  and 
rectum,  p.  513;  Dysenteric  proctitis,  p.  513. 

Abscess  and  Fistula  in  Ano,  p.  514:  Abscess,  p.  514.  Fistula,  p.  516: 
Varieties,  p.  516;  1.  Complete,  p.  516;  Horseshoe  fistula,  p.  516;  2.  Incom- 
plete, p.  517;  Blind  external  fistula,  p.  517;  Blind  internal  fistula,  p.  517; 
Symptoms,  p.  518;  Physical  examinations,  p.  518. 

Stricture  of  the  Rectum,  p.  518:  Congenital  strictures,  p.  519;  Strictures 
due  to  pressure  on  the  rectum  from  without,  p.  519.  Inflammatory  strictures, 
p.  519;  Pathology,  p.  519;  Symptoms,  p.  520;  Physical  examination,  p.  520. 

Prolapse  of  the  Rectum,  p.  521 :  Symptoms,  p.  521.  Physical  examination, 
p.  522. 

New  Growths  of  the  Rectum,  p.  522:  1.  Benign  tumors,  p.  522;  (a). 
Tumors  about  the  anus,  p.  522,  Papilloma,  p.  522;  Soft  fibroma,  p.  523; 
Lipoma,  p.  523.  (6).  Tumors  of  the  rectum,  Polypi,  p.  523;  Adenoma  or 
mucous  polyp,  p.  523;  Fibro-adenoma,  p.  523;  Lymph-adenoma,  p.  523; 
Glandular  polypi,  p.  524;  Fibroma  or  fibrous  polyp,  p.  524;  Myoma,  p. 
524;  Villous  tumor,  p.  524;  Myomatous  polyp,  p.  525.  2.  Malignant 
tumors,  p.  525;  Cancer  of  the  rectum,  p.  525;  Cancer  of  the  anus,  p.  526, 
Pathology,  p.  526,  Symptoms,  p.  527,  Diagnosis,  p.  528,  Differential  diag- 
nosis, p.  528;  Sarcoma  of  the  rectum,  p.  529,  Varieties,  p.  529,  Diagnosis, 
p.  530. 

A  SHORT  sketch  of  the  chief  points  in  the  anatomy  and  physiology 
of  the  rectum,  as  well  as  a  description  of  the  methods  of  examination, 

494 


ANOMALIES 


495 


will  be  found  in  Chapter  IX.,  page  121.    An  analysis  of  the  chief 
symptoms  of  rectal  disease  is  given  in  Chapter  X.,  page  156. 


ANOMALIES 

The  different  stages  of  the  development  of  the  rectum  and  anus 
are  shown  diagrammatically  in  the  figures  from  Schroeder  on 
page  395,  Figs.  158-162,  Chapter  XXI.  As  it  is  not  the  general 
custom  for  obstetricians  to  examine  carefully  the  anus  and  rectum 
of  the  new-born  infant,  many  minor  malformations  pass  unob- 
served. Where  a  careful  examination  is  made  some  degree  of  mal- 
formation will  be  found  not  so  infrequently.  Starr  has  estimated 


FIG.  191. — The  Anal  Canal.  A,  Columns  of  Morgagni;  B,  Semilunar  valves 
or  Crypts  of  Morgagni;  C,  Dentate  Border  Marking  Upper  Limits  of  Anus  and 
surmounted  by  Papillae;  D,  Hilton's  White  Line.  (Tuttle.) 

that  anal  and  rectal  malformation  occurs  about  once  in  ten  thou- 
sand births.  It  is  more  common  in  girls  than  in  boys,  if  we 
include  anus  vaginalis  (see  page  393,  Chapter  XXL).  As  shown  in 
the  diagrams  on  page  395  the  rectum  and  the  anus  are  developed 
from  entirely  different  structures  of  the  blastoderm,  the  former 
from  the  hind-gut,  and  the  latter  from  the  proctodeum,  a  depression 
in  the  epi-blast  opposite  the  lower  end  of  the  hind-gut,  therefore 
malformation  of  the  one  does  not  necessarily  imply  abnormality 
of  the  other.  As  a  matter  of  fact,  if  the  rectum  is  malformed 
or  displaced  the  amis  is  generally  normal,  and  vice  versa. 

Malformation  of  either  of  these  organs  is  likely  to  be  associated 
with  malformation  in  other  portions  of  the  body  that  are  derived 


496 


DISEASES  OF  THE  RECTUM 


from  the  same  layer  of  tho  blastoderm.     For  instance,  children 
with  anomalies  of  the  rectum  are  apt  to  suffer  with  cleft  palate. 

Many  of  the  developmental  defects  are  associated  with  non- 
viability  and  monstrosities.  The  following  anomalies  have  been 
described: 


1.  ARREST  OR  IRREGULAR  DEVELOPMENT  OF  THE  HIND-GUT 

Sir  Charles  Ball  ("The  Rectum,  Its  Diseases  and  Developmental 
Defects")  reports  the  case  of  a  child  three  months  old,  in  which 
the  rectum  was  entirely  absent,  also  the  entire  colon,  the  ileum 

opening  in  the  center  of  an  ex- 
strophy of  the  bladder.  The 
external  genitals  were  also 
wanting.  Children  born  with 
such  defects  must  necessarily 
be  short  lived. 

Imperforate  Rectum.  —  This 
is  a  common  malformation,  the 
bowel  ending  in  an  open  tube 
on  a  level  with  the  reflection  of 
the  peritoneum  on  the  rectum, 
presumably  due  to  the  failure 
of  the  hind-gut  to  send  out  a 
bud,  the  post-allantoic  gut,  to 
meet  the  proctodeum.  The 
condition  may  or  may  not 
be  associated  with  imperf orate 
anus.  If  it  is,  the  condition  is 
recognized  at  once  by  inspec- 
tion ;  if  not,  the  infant  is  gener- 
ally dosed  with  cathartics,  and  only  when  grave  symptoms  of 
obstruction  supervene,  is  a  thorough  examination  made.  The 
physician  should  make  it  a  rule  to  institute  a  thorough  physical 
examination  if  an  infant's  bowels  have  not  moved  within  the  first 
twenty-four  hours  of  life.  If  the  anus  appears  to  be  normal  ex- 
ternally, introduce  the  well-anointed  tip  of  the  little  finger  and 
determine  whether  the  anal  canal  is  patent. 

Imperforate  Rectum  with  Outlet  into  the  Urethra  or  Bladder. — In 


FIG.  192. — Cast  of  Rectum  and  Anal 
Canal.  (Tuttle,  after  Quenu  and  Hart- 
mann.) 


ANOMALIES  497 

this  anomaly  there  has  been  a  persistence  of  the  allantoic  opening 
with  failure  of  the  rectum  to  end  in  the  anus.  If  the  opening  is 
into  the  urethra  (a  condition  usually  found  in  the  male)  there  is 
an  escape  of  flatus  and  meconium  from  the  urethra  together  with 
the  urine;  if,  on  the  other  hand,  the  opening  is  into  the  bladder  the 
meconium  and  feces  become  mixed  with  the  urine  and  sooner  or 
later  the  individual  succumbs  to  ascending  infective  ureteritis  and 
kidney  disease,  even  if  the  outlet  is  large  enough  to  obviate  intes- 
tinal obstruction. 

Imperforate  Rectum  with  Outlet  into  the  Vagina. — This  is  a  per- 
sistence of  the  urogenital  sinus  and  is  met  with  not  infrequently. 
The  opening  may  occur  at  any  point  in  the  vagina  and  is  generally 
large  enough  to  permit  the  passage  of  meconium  or  even  solid  feces. 
An  imperforate  hymen  may  obstruct  the  escape  of  the  feces  from 
the  vagina,  and  in  this  case  there  is  present  a  bulging,  greenish 
membrane  in  the  situation  of  the  introitus. 

The  rectum  has  been  known  to  be  imperforate  and  to  connect 
with  the  uterus,  and  also  to  open  on  the  back  near  a  spina  bifida; 
and  the  rectum  may  open  normally,  but  have  connected  with  it 
ureters,  uterus,  or  vagina.  Also,  diverticula  in  the  lower  rectum 
are  sometimes  found. 

2.  ARREST  OR  IRREGULAR  DEVELOPMENT  OF  THE  PROCTODEUM 

Imperforate  Anus. — There  may  be  no  trace  of  the  anus,  or  its 
situation  may  be  marked  by  a  slight  depression,  or  by  a  wart-like 
prominence ;  this  constitutes  entire  absence  of  development  of  the 
proct  odeum. 

Imperforate  Anus  with  Anal  Canal  Ending  in  the  Vulva. — This  is 
a  very  common  anomaly  and  is  confounded  with  imperforate 
rectum  having  a  vaginal  outlet.  Women  with  this  anomaly  may 
have  children  and  live  to  an  advanced  age  without  realizing  that 
they  arc  abnormal,  as  they  may  have  perfect  control  over  the 
vulvar  anus.  Incontinence  of  feces  is  common  in  these  cases, 
however. 

Anus  Well  Formed ;  Anal  Canal  Ending  above  in  a  Cul-de-sac.— In 

this  malformation  the  proctodeum  develops  a  normal  anus,  but  the 

anal  canal  is  imperforate  above.    The  condition  may  be  associated 

with  imperforate  rectum,  but  often  the  rectum  is  normal  and  only 

32 


498  DISEASES  OF  THE  RECTUM 

a  membranous  septum  separates  its  cavity  from  the  anal  canal. 
The  child  on  straining  may  cause  this  septum  to  protrude  from 
the  anus. 

Abnormally  Small  Anus. — The  anus  may  be  abnormally  small 
(see  Congenital  Stricture  of  the  Rectum,  page  519),  or  it  may  be 
divided  into  two  parts  by  a  median  longitudinal  septum. 


HEMORRHOIDS  OR  PILES 

Hemorrhoids  or  piles  are  tumors  composed  chiefly  of  dilated 
blood-vessels  or  blood-clots,  situated  beneath  the  mucous  membrane 
or  skin  of  the  anus  or  lower  rectum.  They  are  (a)  external,  when 
the}"  are  on  the  outside  of  the  anus,  either  as  exaggerations  of  some 
of  the  natural  ruga)  of  the  skin  around  the  anus,  or  rounded  or 
elongated  venous  tumors  situated  at  the  margin  of  the  anus;  or, 
they  are  (6)  internal,  tumors  originating  within  the  anal  canal  or 
in  the  ampulla,  capable,  perhaps,  of  being  forced  outside.  Both 
sorts  of  piles  may  exist  in  the  same  patient.  Histologically  a  pile 
is  seen  to  be  made  up  not  only  of  the  dilated  veins,  writh  thickened 
walls,  but  also  of  a  considerable  amount  of  connective  tissue,  the 
latter  being  more  in  evidence  in  cases  of  long  duration. 

The  terms  hemorrhoids  and  piles  are  used  interchangeably,  but 
the  former  (from  the  Greek  altj.t,ppoia)  a  discharge  of  blood)  ap- 
pears to  have  the  better  authority,  perhaps  because  it  appears 

in  the  Bible.  In  1  Samuel,  v.  9,  we  find: — " the  hand  of  the 

Lord  was  against  the  city  with  a  very  great  destruction;  and  he 
smote  the  men  of  the  city,  both  small  and  great,  and  they  had 
emerods  in  their  secret  parts." 

The  term  pile,  signifying  a  ball  (from  the  Latin,  pila),  would  seem 
to  be  fully  as  descriptive  as  hemorrhoid,  but  having  been  used 
extensively  by  the  quacks  has  fallen  into  disrepute. 

Frequency  and  Etiology. — The  disease  is  extremely  common  and 
few  persons  pass  middle  life  without  having  suffered  from  it.  It 
appears  to  be  more  common  among  men  than  women,  although 
authors  vary  in  their  estimation  of  the  relative  frequency.  Perhaps 
five  men  to  three  women  is  a  fair  statement. 

Hemorrhoids  are  more  often  found  in  middle  age,  although  cases 
are  on  record  as  young  as  six  months,  one  author  haying  reported 


1.  THROMBOTIC    H/EMORRHGIDS  2-  INFLAMED   HEMORRHOIDS  WITH    EROSION 

mm 


3.   INTERNAL    H/CMORRHOIDS 
WITH    CEDEMA   OF   ANAL    MARGIN 


4.    PROLAPSING    INTERNAL   HAEMORRHOIDS 


Fiu.  193.— Types  of  Hemorrhoids.     (J.  P.  Tuttle.) 


499 


500  DISEASES  OF  THE  RECTUM 

thirty-nine  children  under  the  age  of  fifteen  years  who  had  hemor- 
rhoids. Heredity  seems  to  play  a  role  in  the  causation,  successive 
generations  of  a  family  suffering  with  the  disease.  The  upright 
posture  apparently  has  to  do  with  the  causation,  for  none  of  the 
domestic  animals  have  hemorrhoids  except,  occasionally,  very 
fat,  over-fed  dogs.  It  is  supposed  that  the  thin-walled,  valveless 
veins  of  the  rectum  are  unable  to 'stand  the  constant  pressure  of  a 
blood  column  of  some  fourteen  inches  in  height,  which  they  are 
subjected  to  when  the  human  frame  is  in  the  upright  position. 

Exciting  causes  are,  overeating,  rich  food,  lack  of  exercise,  and 
sedentary  occupations.  Violent  straining,  as  in  lifting  heavy 
weights,  or  straining  at  stool,  may  cause  a  hemorrhoidal  condition 
of  the  veins  of  the  anus,  and  thrombotic  hemorrhoids  are  nearly 
always  caused  in  this  way. 

Heart  disease,  kidney  disease,  and  cirrhosis  of  the  liver  must  be 
classed  as  exciting  causes,  but  chronic  constipation  with  the  passage 
of  solid  fecal  masses  along  the  rectum,  stripping  the  venous  blood 
away  from  the  heart,  is  one  of  the  chief  direct  causes.  Uterine 
diseases  are  reckoned  as  causative  of  piles.  Certain  it  is  that  the 
two  are  frequently  associated. 

External  Hemorrhoids. — There  are  two  varieties  of  external 
hemorrhoids,  (a)  redundant  folds  of  the  skin  about  the  anal  opening, 
and  (6)  venous  tumors,  (a)  The  normal  corrugations  of  the  skin 
surrounding  the  anus  may  be  exaggerated  and  little  tabs  of  skin 
and  connective  tissue  result.  These  may  be  of  little  significance; 
on  the  otner  hand,  they  are  capable  of  being  inflamed,  or  even 
suppurating  and  of  leaving  behind  more  or  less  induration.  Con- 
stipation is  the  direct  cause.  The  piles  may  cause  itching  and,  when 
inflamed,  smarting,  rendering  sitting  uncomfortable.  If  there  is 
suppuration,  the  symptoms  arc  those  of  abscess.  Examination 
shows  retained  secretion  or  fecal  matter  between  the  ruga?  and 
the  pile  will  be  found  to  be  red,  glistening,  and  perhaps  excoriated. 
(6)  The  superficial  veins  of  the  margin  of  the  anus  become  dilated 
and  the  condition  may  involve  the  entire  circumference  of  the  anus. 
The  veins  belong  to  the  inferior  hemorrhoidal  plexus.  The  swelling 
may  be  limited  to  one,  two,  or  three  circumscribed  tumors.  In 
any  event  the  swelling  is  marked  during  straining  efforts  and 
almost  completely  subsides  soon  after,  leaving  the  skin  loose  and 
redundant  when  the  straining  has  ended.  There  is  no  induration 


HEMORRHOIDS  .501 

^GLLfir.fl  GF  OS 

or  excoriation.  The  chief  complaint  is  difficulty  i%  defecation  and  , 
also  a  feeling  of  fullness  at  the  anus.  The  patient  feels  that  her 
bowels  should  be  emptied,  but  she  can  not  accomplish  it  even  by 
persistent  straining  and  there  is  much  soreness  lasting  after  stool. 
In  the  case  of  this  sort  of  piles  there  may  be  acute  attacks  of  spasm 
of  the  sphincter  attended  by  great  burning  and  itching,  very 
commonly  just  after  the  patient  has  gone  to  bed  at  night,  or  after 
defecation. 

The  patient  being  on  her  side  and  relaxed,  examination  shows 
the  skin  of  the  anus  loose  and  redundant  and  the  sphincter  tightly 
closed.  If  the  piles  are  thrombosed  there  will  be  small,  oval  or 
round  tumors,  varying  in  size  from  a  pea  to  a  walnut,  situated 
just  beneath  the  skin,  the  color  being  that  of  the  normal  skin,  or 
varying  from  red  to  dark  blue.  This  is  the  sort  of  pile  that  causes 
sudden  symptoms  of  sharp,  cutting  pain  when  the  thrombosis 
occurs. 

On  straining,  the  anal  orifice  forms  the  apex  of  a  cone-like  prom- 
inence, and  flatus  or  a  little  rectal  mucus  may  escape.  When 
the  finger  is  passed  through  the  anus,  the  sphincter  grips  it  tightly 
and  hinders  its  easy  introduction.  The  sphincters  are  abnormally 
strong  and  the  rectum  is  apt  to  be  dilated  and  contain  flatus,  or  even 
feces.  Sometimes  a  chronic  condition  of  this  sort  is  productive 
of  rectocele. 

Internal  piles  may  complicate  the  external  piles  and  should  be 
sought  for. 

Many  physicians,  as  well  as  the  laity,  assume  that  all  piles  origi- 
nate in  the  rectum  and  have  come  down,  and  therefore  urge  their 
patients  to  replace  them.  Of  course,  replacement  should  not  be 
attempted  unless  the  piles  are  internal. 

External  piles  should  be  handled  gently,  it  being  a  mistake  to 
squeeze  the  thrombosed  hemorrhoids  with  the  object  of  forcing 
out  the  clot,  for  at  any  time  the  tumor  may  become  infected  and 
trauma  will  assist  in  gaining  entrance  for  the  germs. 

Internal  Hemorrhoids.— Internal  piles  consist  of  a  varicose  con- 
dition of  the  veins  of  the  lowest  two  and  a  half  inches  of  the  rectum. 
Not  all  of  this  region  is  affected  in  most  cases,  and  the  lower  part, 
the  anal  canal,  is  the  place  where  internal  hemorrhoids  are  most 
often  found.  The  internal  pile  is  apt  to  be  pear-shaped,  because 
the  vein  (a  branch  of  the  superior  hemorrhoidal  plexus)  issuing 


502  DISEASES  OF  THE  RECTUM 

from  it,  passes,  upward  in  the  submucous  tissue  and  soon  loses  its 
varicosity,  the  lower  end  only  being  bulbous.  Generally  there  are 
several  of  these  venous  tumors  placed  parallel  to  one  another. 
On  dissection,  this  variety  of  hemorrhoid  consists  of  a  mass  of 
dilated  veins  and  connective  tissue.  In  thrombosed  piles  there  is 
a  blood  clot  and  more  connective  tissue.  Constipation  and  heredity 
seem  to  play  the  chief  roles  in  the  causation. 

The  symptoms  arc  hemorrhage  and  the  protrusion  of  the  pile 
through  the  anus. 

The  amount  of  blood  lost  may  be  slight  and  occur  only  at  stool, 
or  it  may  be  excessive  and  come  on  at  irregular  periods.  It  is 
difficult  to  judge,  from  the  description  of  the  patient,  how  much 
blood  is  lost,  and  one  must  always  remember  that  blood  lost  per 
anum  is  not  necessarily  from  the  rectum,  but  may  come  from  the 
stomach,  duodenum,  or  ileum.  If  from  the  latter  situations  it  will 
be  dark  colored  and  tar-like  in  consistency,  whereas  if  from  the 
rectum  it  will  be  less  dark;  it  may  be  arterial  and  more  or  less 
mixed  with  mucus  or  feces.  Generally  blood  from  internal  hemor- 
rhoids is  passed  after  stool. 

Protrusion  of  the  hemorrhoid  does  not  come  on  until  after  the 
tumor  has  existed  a  considerable  time  and  has  attained  a  large 
size.  At  first  the  pile  recedes  spontaneously,  but  as  it  gets  down 
farther,  the  sphincter  contracts  firmly  and  prevents  its  return. 
In  bad  cases,  rest  in  bed,  with  the  hips  elevated,  may  be  necessary 
before  reduction  can  be  accomplished,  but,  as  a  rule,  the  pile  can  be 
pushed  up  after  it  has  been  anointed. 

An  excess  of  mucus  is  generally  associated  with  internal  hemor- 
rhoids and  there  may  be  a  sense  of  weight,  or  aching  in  the  sacral 
region,  or  even  pain  in  the  anus,  when  the  pile  is  prolapsed. 

Examination  shows  edema  of  the  skin  about  the  anus  in  the 
form  of  one  or  more  soft  elastic  folds;  this  swelling  is  more  marked 
if  the  piles  arc  strangulated  and  is  due  to  the  obstruction  of  the 
venous  return.  The  patient  is  asked  to  strain,  and  if  the  piles  are 
well  developed  they  come  into  view  as  purplish  tumors,  the  anus 
being  below  its  natural  position.  The  finger  inserted  into  the  rec- 
tum detects  the  hemorrhoids  as  elastic  tumors,  perhaps  pedicled, 
and  hard  if  thrombosed. 

Hemorrhoids  of  the  anterior  wall  of  the  rectum  may  be  inspected 
by  everting  the  wall  of  the  rectum,  in  the  case  of  women  who  have 


FISSURE  IN  ANO  503 

had  children,  by  pressure  with  a  finger  in  the  vagina.  In  virgins,  the 
pelvic  floor  is  too  rigid  to  permit  of  this  procedure.  The  sphincters 
are  hypertrophied  except  in  long-standing  cases,  when  they  do  not 
appear  to  have  the  normal  contractile  power. 

By  the  use  of  the  short  proctoscope,  piles  may  be  seen  as  bluish 
tumors  projecting  from  the  mucous  membrane. 

FISSURE  IN  ANO 

Anal  fissure,  or  irritable  ulcer,  signifies  a  superficial  ulcer  situated 
in  one  of  the  sulei  between  the  folds  of  the  mucosa  of  the  anal  canal. 
It  is  almost  always  single,  it  is  pear-shaped  or  triangular  in  form,  is 
always  in  the  long  axis  of  the  canal,  and  varies  in  length  from  three- 
eighths  to  seven-eighths  of  an  inch  (9  millimeters  to  2.1  centi- 
meters). It  is  from  a  quarter  of  an  inch  (6  millimeters)  to  half  an 
inch  (1.2  centimeters)  broad,  the  wider  part  being  generally  below 
and  in  the  skin  of  the  anus.  At  the  lower  limit  of  the  fissure,  or 
just  to  one  side  of  it,  there  is  sometimes  a  small  fold  of  skin  called 
"a  sentinel  pile." 

Fissure  is  most  often  found  on  the  posterior  surface  of  the  anal 
canal,  although  it  may  be  on  any  side.  In  cases  of  long  standing 
the  ulceration  may  reach  in  depth  to  the  sphincter  muscle;  as  a 
rule  it  is  superficial. 

The  disease  occurs  in  all  ages  and  conditions  of  life,  but  is  chiefly 
found  in  adult  life  and  especially  in  women  during  the  childbearing 
period. 

Constipation  is  the  cause  Of  fissure;  hard,  dry,  scybalous  masses 
tearing  the  delicate  mucous  membrane  while  being  voided. 

Symptoms. — The  symptoms  are  pain,  muscular  spasm,  and 
occasional  loss  of  blood.  The  pain  seems  to  be  out  of  all  proportion 
to  the  size  of  the  lesion  and  is  described  as  a  burning,  aching,  anil 
throbbing  sensation  just  within  the  anus.  It  begins  while  the 
feces  are  being  passed  (it  may  be  delayed  for  half  an  hour)  and 
lasts  from  half  an  hour  to  six  or  eight  hours,  to  return  when  the 
next  motion  of  the  bowels  takes  place.  The  patient  is  induced  to 
put  off  defecation  because  of  the  discomfort  and  thus  the  fissure  is 
aggravated.  The  spasm  of  the  sphincter  causes  great  pain  and 
also  interferes  with  defecation,  besides  diminishing  the  diameter 
of  the  fecal  mass. 


504  DISEASES  OF  THE  RECTUM 

Diagnosis. — Inspection  shows  a  fissure,  when  the  buttocks  are 
widely  separated,  and  the  skin  of  the  anus  is  apt  to  be  redundant 
and  thrown  into  exaggerated  folds  in  these  cases.  The  external 
sphincter  is  palpated  to  detect  abnormal  thickening  or  induration, 
and  when  the  patient  is  asked  to  strain  down,  the  amount  of  spasm 
of  the  sphincter  may  be  estimated,  the  straining  causing  pain  in 
the  fissure.  Discharge  from  the  fissure,  small  in  amount  and 


FIG.  194.— Fissure  in  Ano.     (Tuttle.) 

non-purulent,  is  to  be  looked  for.  Digital  exploration  of  the  rectum 
should  be  made,  with  an  anesthetic  if  the  pain  is  too  severe,  prep- 
arations being  made  at  the  same  time  to  treat  the  suspected 
fissure,  so  that  only  one  anesthetization  may  be  necessary.  The 
ulcer  is  felt  as  a  roughened  patch  in  the  smooth  mucosa  of  the  anal 
canal. 

If  the  situation  of  a  fissure  can  be  determined,  the  finger  should 


INFLAMMATION  OF  THE  RECTUM  505 

be  pressed  against  the  opposite  wall  to  cause  as  little  pain  as 
possible.  The  spasmodic  contraction  of  the  sphincters  and  leva- 
tores  ani  is  now  apparent  and  feces  are  apt  to  be  found  in  the 
rectum.  The  rectum  should  be  cleared  by  enema  and  further  ex- 
amination made.  The  complications  of  anal  fissure,  such  as  polypi, 
piles,  and  blind  internal  fistula,  are  generally  situated  in  the  lowest 
part  of  the  rectum.  Unless  the  patient  is  anesthetized  it  is  not 
wise  to  pass  the  proctoscope  in  the  case  of  fissure,  because  of  the 
great  pain  caused. 

Differential  Diagnosis. — Simple  fissure  must  be  differentiated 
from 

Syphilitic  Fissure. — The  latter  are  generally  multiple  and  are 
on  the  right  or  left  of  the  anus,  not  in  the  middle  line;  they  cause 
pain  that  begins  during  defecation  but  does  not  persist  so  long  as 
in  simple  fissure  and  is  apt  to  recur  at  night.  The  inguinal  or  the 
femoral  lymphatic  glands  will  be  found  to  be  enlarged  individually, 
and  there  is  a  history  of  syphilis. 

Blind  internal  fistula  is  attended  by  a  history  of  continuous 
pain,  which  is  accentuated  by  defecation  but  does  not  cease  en- 
tirely. It  is  accompanied  by  a  periodic  discharge  of  pus,  with  the 
relief  of  pain,  except  during  defecation.  Pus  can  generally  be  seen 
issuing  from  the  bowel  in  cases  of  blind  internal  fistula,  and  the 
finger  introduced  in  the  rectum  will  be  found  to  be  streaked  with 
pus  on  its  withdrawal,  and  instead  of  a  roughened  patch,  as  in 
fistula,  the  ball  of  the  finger  feels  induration.  Perhaps  a  depression 
can  be  felt  and  a  bent  probe  can  be  passed  into  the  fistula. 


INFLAMMATION  OF  THE  RECTUM— PROCTITIS 

Inflammation  of  the  rectum  may  be  divided  into 

1.  Simple,  those  inflammations  of  unknown  bacterial  origin,  or 

2.  Specific,  those  inflammatory  processes  due  to  the  bacteria  of 
gonorrhea,  syphilis,  tuberculosis,  or  dysentery. 

An  inflammation  affecting  the  rectum  generally  involves  the 
colon  as  well,  because  the  two  are  similar  structures  anatomi- 
cally and  parts  of  one  canal,  therefore  it  is  not  always  possible 
while  considering  proctitis  to  rule  out  colitis. 

The  absorptive  power  of  the  rectal  mucosa  is  considerable,  as 


506  DISEASES  OF  THE  RECTUM 

is  attested  by  the  rapidity  with  which  fluids  injected  into  the 
rectum  are  taken  into  the  circulation.  It  is  here  that  the  fluid 
contents  of  the  intestine  are  rendered  semisolid  or  solid  by  the 
abstraction  of  their  watery  constituents,  therefore  it  is  not  surpris- 
ing that  the  bacteria  from  the  feces,  especially  if  the  solid  parts 
cause  abrasions,  should  find  lodgment  in  the  walls. 

As  a  matter  of  fact,  the  rectum,  especially  in  its  lower  part, 
seems  to  be  relatively  immune  to  septic  infection,  just  as  in  the 
case  of  the  lips  and  mouth  and  the  other  openings  of  the  body. 
The  inflammatory  process  may  be  of  mild  grade,  catarrhal  proctitis, 
or  it  may  progress  to  ulceration,  ulccrative  proctitis. 

1.  SIMPLE  PROCTITIS 

•  Simple  catarrhal  inflammation  of  the  rectum  is  a  common 
disease,  especially  in  women  who  have  uterine  disease.  It  may  be 
(a)  acute,  or  (6)  chronic. 

(a)  Acute  catarrhal  proctitis  may  be  caused  by  pin-worms,  im- 
pacted fcces  or  foreign  bodies,  or  by  prolapse  of  the  rectum.  Other 
causes  are:  highly  seasoned  food:  sitting  on  cold  stone,  wet  seats,  or 
the  damp  ground;  irritating  cathartics,  such  as  jalap,  aloes, 
gamboge,  and  podophyllin.  Fermentation  and  putrefaction  of  the 
intestinal  contents  may  be  direct  causes  of  acute  proctitis. 

Symptoms. — The  symptoms  are  a  sense  of  discomfort  and  fullness 
in  the  region  of  the  rectum,  with  tenesmus,  and  the  forcible  ejection 
of  fluid  feces  through  an  anus  made  small  by  irritation  of  the 
sphincter.  There  may  be  pain  in  the  pelvis,  radiating  into  the  back 
and  thighs.  The  patient  has  less  discomfort  while  lying  down 
than  when  erect  and  there  may  be  slight  fever. 

Frequent  desire  for  an  evacuation  of  the  bowels  is  a  prominent 
symptom  from  the  first,  and  defecation  does  not  remove  the  desire, 
the  straining  even  causing  prolapse  of  the  rectum  sometimes  in 
children. 

The  discharges  are  fluid  and  after  the  first  twenty-four  hours 
may  be  tinged  with  blood  or  pus.  The  process  is  confined  to  the 
inucosa,  as  a  rule,  in  acute  proctitis,  though  the  inflammation  may 
be  so  severe  that  portions  of  the  mucous  membrane  arc  cast  off 
and  the  dee] XT  layers  affected  also.  In  the  latter  event,  ulceration, 
abscess,  fistula,  or  stricture  may  follow. 


INFLAMMATION    OF  THE    RECTUM  507 

Examination  shows  great  tenderness  when  an  attempt  is  made  to 
introduce  the  finger  or  speculum  into  the  rectum  and  the  sphincter 
is  contracted.  The  mucous  membrane  feels  hot,  dry,  and  swollen 
in  the  very  early  stages,  and  later  very  moist.  Through  the  proc- 
toscope, at  first,  it  is  of  a  light  red  color  throughout,  or  deep  red  in 
patches  and  lighter  red  elsewhere;  later,  the  color  is  darker  red 
and  the  surface  is  covered  in  places  with  opaque  yellowish  mucus. 
Slight  trauma,  even  from  wiping  away  the  secretions,  causes 
bleeding. 

(6)  Chronic  catarrhal  proctitis  may  follow  acute  catarrhal  inflamma- 
tion of  the  rectum,  or,  as  far  as  we  know,  it  may  be  chronic  from 
the  beginning.  The  latter  is  true  of  atrophic  catarrhal  proctitis, 
the  most  frequent  type  of  catarrhal  proctitis.  Hypertrophic  catar- 
rhal proctitis,  the  other  form,  although  generally  chronic  in  course, 
may  show  an  acute  stage. 

ATROPHIC  PROCTITIS. — This  consists  of  an  atrophy  of  the  mucous 
membrane  and  its  glandular  elements  throughout  the  rectum. 
It  is  limited  to  the  rectum;  not,  like  the  hypertrophic  variety, 
affecting  the  colon  also.  The  disease  is  found  mostly  in  adult  life 
and  is  probably  due  to  sedentary  occupation,  the  overeating  of 
highly  spiced  food,  chronic  constipation,  and  the  abuse  of  cathartics 
and  cnemata.  The  affection  is  not  infrequently  associated  with 
syphilis,  either  acquired  or  hereditary.  Sometimes  it  is  associated 
with  chronic  pelvic  inflammation.  J.  P.  Tuttle  has  noted  the 
association  of  this  form  of  rectal  catarrh  with  chronic  catarrh  of  the 
nose,  and  C.  B.  Kelsey  calls  attention  to  the  frequency  with  which 
gynecologists  overlook  this  disease  and  the  possibility,  if  an  ulcer- 
ative  stage  has  been  reached,  of  its  causing  subsequent  stricture 
of  the  rectum. 

Pathological  examination  of  the  tissues  of  a  rectum  affected  by 
chronic  atrophic  proctitis  shows  the  mucosa  to  be  granular,  dry, 
inelastic,  and  adhering  to  it  small  masses  of  dry  feces  and  perhaps 
shreds  of  exfoliated  epithelium.  Under  the  microscope  the  epithe- 
lium is  found  wanting  in  many  places  on  the  surface  and  there  are 
granulations  and  ulcerated  areas.  The  crypts  of  Lieberkiihn  are 
atrophied,  the  solitary  follicles  are  enlarged  and  distended,  and 
the  connective  tissue  of  the  submucosa  is  increased  in  amount. 

The  xi/m)>toms  are  those  of  a  mild  irritation  of  the  rectum.  As 
the  disease  is  apt  to  be  complicated  by  fissure  and  hemorrhoids, 


508  DISEASES  OF  THE  RECTUM 

the  symptoms  arc  more  directly  caused  by  these  affections.  Long- 
continued  constipation,  with  hard  and  lumpy  stools  and  burning 
and  discomfort  in  the  rectum,  may  be  the  only  symptoms,  the 
latter  being  often  mistaken  for  chronic  disease  of  the  ovaries  or 
tubes.  Pruritus  ani  is  a  common  symptom. 

Examination  shows  the  skin  of  the  anus  relatively  normal,  and 
the  mucous  membrane  of  the  rectum  bright  red  and  shiny,  with 
small  pieces  of  dry  feces  adhering  to  it  in  places.  It  does  not  bulge 
into  the  end  of  the  proctoscope.  To  the  examining  finger,  the 
mucosa  feels  dry  and  it  sticks  to  the  finger.  In  long-standing 
cases  the  rugae  seem  to  be  obliterated  and  the  valves  of  Houston 
stand  out  more  prominently,  while  the  ampulla  is  dilated.  Erosion 
and  ulceration  are  not  uncommon.  In  such  cases  the  stools  may 
be  smeared  with  blood  or  pus,  and  the  eroded  or  ulcerated  areas 
may  be  seen  through  the  proctoscope. 

HYPERTROPHIC  PROCTITIS. — This  is  a  chronic  inflammation  of  the 
rectal  mucous  membrane,  in  which  the  mucosa  and  submucosa 
are  thickened.  The  disease  involves  the  colon  as  well  as  the  rectum, 
being  a  part  of  an  inflammatory  process  affecting  the  entire  large 
intestine,  and  it  generally  follows  an  acute  attack  of  proctitis  or 
colitis.  The  affection  is  found  most  often  in  fat,  flabby  individuals 
who  are  the  victims  of  chronic  constipation,  and  occurs  also  in  cases 
of  chronic  catarrhal  appendicitis,  uterine  malpositions,  abdominal 
tumors  pressing  on  the  intestine,  and  in  movable  kidneys,  which 
slide  up  and  down  on  the  bowel. 

Pathological  examination  of  the  rectal  wall  shows  marked 
hypertrophy  of  all  the  elements  of  which  it  is  composed,  including 
the  glands  and  the  connective  tissue  of  the  mucosa  and  submucosa. 

The  symptoms  are  apt  to  be  more  general  than  local.  Where 
the  disease  follows  a  well-marked  acute  attack,  there  will  be  a  lessen- 
ing in  the  severity  of  the  symptoms.  As  chronic  hypertrophic 
proctitis  is  a  part  of  a  colitis  and  a  large  area  of  intestine  is  involved, 
the  symptoms  are  of  more  serious  moment  than  is  the  case  in  atro- 
phic  proctitis.  They  are:  diarrhea  alternating  with  constipation, 
the  stools  being  soft  and  mixed  with  pus,  or  hard  and  round,  like 
sheep-droppings,  and  covered  with  muco-pus.  Tenderness  on  pres- 
sure over  the  course  of  the  colon  in  the  abdomen,  with  swelling  of 
the  abdomen  and  griping  pains,  may  be  a  feature  of  the  case.  In 
cases  of  a  pronounced  character,  there  may  be  tenesmus,  occurring 


INFLAMMATION   OF   THE   RECTUM  509 

periodically  and  accompanied  by  the  discharge  of  a  large  quantity 
of  thick  glairy  mucus  or  muco-pus.  Mucus  may  escape  invol- 
untarily in  these  cases  to  such  an  extent  that  the  patient  is  forced 
to  wear  a  napkin.  Pruritus  is  a  common  and  a  troublesome  symp- 
tom. Constitutional  symptoms  are:  flatulence,  loss  of  appetite, 
coated  tongue,  yellow  skin,  offensive  breath,  and  loss  of  weight  and 
strength. 

Examination  shows  redness  of  the  skin  and  hypertrophy  of 
the  rugae  about  the  anus  due  to  the  irritation  caused  by  abundant 
mucus  coming  from  the  anus.  Dermatitis  may  exist  in  extreme 
cases,  with  much  thickening  of  the  skin.  Condylomata  acuminata, 
with  their  characteristic  tree-like  growth,  are  not  uncommon  in 
the  skin  about  the  anus. 

By  digital  examination,  the  mucous  membrane  of  the  rectum 
feels  doughy,  and  the  cavity  of  the  gut  seems  somewhat  restricted; 
quite  the  opposite  to  the  state  of  the  case  in  atrophic  proctitis. 

Through  the  proctoscope,  the  flabby  redundant  mucosa  bulges 
into  the  end  of  the  proctoscope.  It  is  pale  red  in  color  and  covered 
with  muco-pus.  It  does  not  bleed  easily  and  neither  ulceration, 
hemorrhoids,  nor  fissure  is  apt  to  complicate  this  form  of  proctitis, 
although  prolapse  may. 

The  following  table  shows  the  principal  points  in  the  differential 
diagnosis  between  the  atrophic  and  the  hypertrophic  forms  of 
proctitis:— 

CHRONIC  ATROPHIC  PROCTITIS  CHRONIC  HYPERTROPHIC 

PROCTITIS 

1.  Constipation  is  generally  the     1.  Constipation  alternating  with 

rule.  diarrhea. 

2.  Secretions  absent;    peri-anal     2.  Secretions  increased  about  the 
skin  dry  and  relatively  nor-  peri-anal  region;   acute  der- 
mal, matitis ;  moist  eczema.  Con- 
dylomata apt  to  be  present. 

3.  Sphincters  usually  contracted     3.  Sphincters  generally  relaxed. 

and  hypertrophied. 

4.  Mucous  membrane  dry,  stools     4.    Mucous    membrane   swollen 

adhesive,  rectum  readily  dis-  and    edematous,     prolapses 

tended  and  easy  to  examine.  over  the  end  of  the  procto- 

scope during  examination. 


510  DISEASES  OF  THE  RECTUM 

CHRONIC  HYPERTROPHIC  CHRONIC    ATROPHIC    PROCTITIS 

PROCTITIS 

(continued)  (continual) 

o.  Mucous     membrane     bleeds  5.    Bleeding   from   the   mucous 

readily;   light  sponging  pro-  membrane  uncommon. 
duces  considerable  oozing. 

6.  Mucous  membrane  dry  and  of  6.  Mucous  membrane  moist  and 

a  bright  red  color.  of  a  pale  red  or  pinkish  hue. 

7.  Ulceration  common.  7.  Ulceration  rare. 

8.  Inflammatory  process  almost     8.  Inflammatory  process  rarely 
invariably   confined   to   the  limited  to  the  rectum   and 
rectum  and  sigmoid.  sigmoid,  the  colon  being  in- 
volved as  well. 

9.  Hemorrhoids  often  present.     9.  Hemorrhoids  an  unusual  com- 
Prolapse  seldom  seen.  plication.    Prolapse  more  fre- 
quent. 

2.    SPECIFIC  PROCTITIS 

Gonorrheal  Proctitis. — This  disease  is  rarely  diagnosed,  though  it 
probably  is  not  so  infrequent  as  formerly  supposed  by  writers  on 
venereal  disease.  It  is  undoubtedly  more  frequent  in  women  than  in 
men  and  is  due  to  the  extension  of  the  disease  from  the  vulva  be- 
cause of  the  introduction  of  the  gonococcus  on  the  finger  or  rectal 
tube,  or  it  may  be  due  to  unnatural  intercourse.  The  symptoms 
and  anatomical  appearances  are  those  of  simple  proctitis  and  the 
diagnosis  is  made  by  the  isolation  of  the  gonococcus  from  the 
discharges. 

Condylomata,  fissure,  and  subrnucous  fistula  are  found  as 
complications. 

Syphilis  of  the  Rectum  and  Anus. — Syphilis  manifests  itself  in  the 
skin  about  the  anus,  in  the  anal  canal,  and  in  the  rectum  proper, 
in  primary,  secondary,  and  tertiary  lesions.  It  may  be  congenital, 
or  it  may  be  acquired  innocently,  or  by  inoculation  by  unnatural 
coitus. 

Congenital  syphilis  is  almost  always  of  the  secondary  type  and 
occurs  in  young  children,  usually  during  the  first  two  or  three 
months  of  life.  The  lesions  consist  either  of  cracks  in  the  skin 
about  the  anus,  radiating  from  the  anus,  or  smooth,  flat,  elevated 


INFLAMMATION  OF  THE  RECTUM  511 

patches,  from  a  quarter  of  an  inch  to  half  an  inch  in  diameter,  in 
the  same  situation.  These  lesions  exude  a  very  contagious  discharge. 
The  diagnosis  is  established  by  finding  the  Spirochseta  pallida  in 
the  discharge  or  scrapings  from  the  lesions,  and  in  the  appearance 
of  syphilitic  lesions  elsewhere  in  the  body. 

As  indicating  the  relative  frequency  of  the  different  syphilitic 
lesions,  the  statistics  of  P.  Sick,  from  the  Hamburg  General  Hospital, 
may  be  quoted.  Among  11,826  women  and  children  treated  there 
for  venereal  diseases,  there  were:  mucous  patches,  986;  chancroids 
of  the  anus,  224;  chancres  of  the  anus,  12;  strictures  of  the  rectum, 
10;  rectal  gummata,  2;  and  anal  gumma,  1. 

Chancre,  the  initial  lesion  of  syphilis,  is  not  uncommonly  found 
about  the  anus  in  women.  Statistics  have  been  published  that  go 
to  show  that  among  women  who  have  syphilis  chancre  is  found 
at  the  anus  in  about  one  in  thirteen.  The  characteristics  of  the 
chancre  in  the  skin  about  the  anus  are  exactly  the  same  as  on  the 
vulva.  (See  page  406.) 

If  the  chancre  is  in  the  anal  canal,  or  rectum  proper,  a  rare 
occurrence,  it  is  apt  to  escape  detection.  Digital  and  visual  ex- 
amination will  detect  a  single,  non-sensitive  lesion,  with  an  indu- 
rated base,  and  the  individual  glands  in  the  groin  will  be  found 
enlarged.  Scrapings  from  the  chancre  will  show  the  Spirocharta 
pallida. 

Mucous  Patches. — The  anus  is  the  most  frequent  seat  of  mucous 
patches  next  to  the  mouth  and  throat;  they  may  begin  on  the  vulva 
and  spread  to  the  anal  regions.  Mucous  patches  do  not  occur  within 
the  rectum,  so  far  as  known.  They  begin  as  a  reddening  of  the 
skin  between  the  folds  of  the  buttocks,  noticed  sometimes  before 
the  initial  lesion  has  healed;  the  chancre,  in  fact,  merging  into  a 
mucous  patch.  As  a  rule  the  mucous  patch  is  developed  with  the 
secondary  lesions,  at  the  same  time  as  the  macular  eruption  upon 
the  skin  of  the  rest  of  the  body.  The  reddened  area  of  skin  is  raised 
a  little  above  the  surrounding  skin;  the  epithelium  becomes 
macerated  and  is  shed,  leaving  a  shallow  erosion.  There  is  a  scanty, 
thin  discharge  and  there  is  no  itching.  Soon  the  surface  of  the 
erosion  is  covered  by  a  grayish- white  membrane  slightly  elevated 
above  the  surface  of  the  skin.  The  patches  vary  in  size  and  may 
be  single,  multiple,  or  coalescing,  so  that  the  entire  circumference 
of  the  anus  is  involved. 


512  DISEASES  OF  THE  RECTUM 

When  tho  papilla)  of  the  mucous  patches  grow  upward  from  the 
skin  they  may  form  flattened  warty  growths  called  condylomata 
lata,  or  vegetating  mucous  patches.  They  are  accompanied  by  more 
or  less  discharge  and  are  more  commonly  found  in  uncleanly 
syphilitics. 

Ulcerations  may  result  from  the  breaking  down  of  mucous  patches. 
Syphilitic  ulcerations  within  the  rectum  are  common.  They  present 
few  symptoms  and  reach  the  chronic  stage  before  they  are  recog- 
nized. They  tend  to  spread,  following  the  course  of  the  blood-vessels 
and  the  lymphatics  and  are  destructive  in  their  tendencies,  having 
been  known  to  perforate  the  peritoneum.  The  lymphatic  glands 
in  the  hollow  of  the  sacrum  become  enlarged  and  may  be  palpated, 
but  must  not  be  mistaken  for  gummata. 

When  the  ulcers  cicatrize  they  leave  behind  them  bluish-white, 
non-elastic  tissue  that  forms  a  stricture. 

Gummata. — Gummata  of  the  anus  are  very  rare  and  only  a  few 
cases  of  gumma  of  the  rectum  have  been  reported.  The  latter  is 
described  as  a  round,  clastic,  painless  tumor,  situated  in  the  sub- 
mucous  tissues.  It  is  single  or  multiple  and  from  the  size  of  a  pea 
to  that  of  a  small  orange.  The  fact  that  a  gumma  does  not  sup- 
purate, is  not  tender,  and  does  not  occur  in  chains,  serves  to  dis- 
tinguish it  from  enlarged  lymphatic  glands. 

Syphilitic  stricture  of  tlie  rectum  is  considered  under  Stricture, 
page  519. 

Chancroids  of  the  Anus  and  Rectum. — This  affection  is  rare  in 
America,  though  not  infrequent  on  the  Continent  abroad.  The 
chancroidal  ulcer,  being  auto-inoculable,  often  extends  from 
the  vulva  (sec  page  406),  therefore  we  may  regard  chancroids 
of  the  anus  as  secondary  in  a  vast  majority  of  cases.  Chancroids 
of  the  rectum  are  generally  due  to  sodomy.  The  points  of  diagnosis 
and  differential  diagnosis  of  chancroids  will  be  found  in  the  chapter 
on  diseases  of  the  vulva,  page  415.  There  is  a  form  of  chancroid 
called  phagedenic,  characterized  by  an  intense  inflammatory  process 
involving  the  deeper  structures,  with  much  destruction  of  tissue. 
This  sort,  if  situated  in  the  rectum,  may  cause  stricture.  It  is  rare, 
and  occurs  commonly  in  patients  of  debilitated  constitution. 

Chancroids  and  chancre  may  coexist  in  the  same  patient,  there- 
fore the  physician  must  be  on  the  watch  for  the  characteristic 
appearance  of  each  lesion. 


INFLAMMATION  OF  THE  RECTUM  513 

Tuberculosis  of  the  Anus  and  Rectum. — Primary  tuberculosis  of 
the  anus  and  rectum  is  extremely  rare;  the  secondary  affection, 
occurring  in  patients  with  advanced  tuberculosis  of  the  lungs  or 
other  organs,  is  not  infrequent. 

A  miliary  variety  of  primary  tuberculosis  in  the  skin  about  the 
anus  has  been  described.  In  this  form  there  are  minute,  shot-like 
bodies  beneath  the  epidermis,  that  have  developed  in  the  sweat 
and  oil  glands  of  the  skin.  They  are  arranged  in  a  crescentic  or 
circular  shape  and  soon  break  down  to  form  shallow  ulcers  with 
ragged,  indurated  edges  and  giving  forth  a  thin  discharge  of  sero- 
pus. 

An  ulcerative  variety  is  the  common  form  in  which  tuberculosis  is 
seen,  both  in  the  skin  about  the  anus  and  inside  the  anal  canal. 
The  ulcerations  are  apt  to  involve  both  the  anal  margin  and  the 
mucous  membrane  inside  the  anal  canal.  They  may  be  single, 
or  on  both  sides  of  the  anus;  they  are  round  or  oval  in  shape,  the 
borders  are  irregular  in  form,  but  undermined,  and  of  a  pale 
color,  shading  to  the  normal  pink  of  the  surrounding  skin.  There 
is  induration  around  the  ulcer,  but  the  base  is  relatively  soft, 
irregular  in  its  surface,  grayish  in  color,  and  the  granulations  do 
not  bleed  easily.  Yellowish  tubercles,  the  size  of  a  millet  seed, 
are  scattered  over  its  surface,  and  in  the  older  parts  of  the  base  of 
the  ulcer  cheesy  material  may  be  found.  The  discharge  is  small 
in  amount,  sero-purulent,  and  mixed  with  blood. 

These  ulcerations  are  not  especially  painful:  they  do  not  tend 
to  heal  as  they  progress  in  all  directions  and  do  not,  like  other 
ulcers,  assume  the  type  of  fissure  when  they  invade  the  anal  canal, 
but  involve  both  the  rugae  and  the  sulci. 

Primary  tuberculosis  of  the  rectum  proper  is  practically  unknown, 
but  the  secondary  type  occurs.  The  ulcerations  present  the  same 
appearance  as  in  the  anal  canal,  ulcerations  here  producing 
stricture  as  their  late  results. 

The  diagnosis  is  made  by  finding  tubercle  bacilli  in  scrapings 
made  from  the  ulcer  and  by  the  characteristics  of  the  ulcer  itself. 

Dysenteric  Proctitis. — This  is  an  inflammation  of  the  rectum 
and  sigmoid  flexure  of  the  colon  occurring  in  sporadic  dysentery, 
and  caused  by  the  ameba  coli.  In  endemic  and  epidemic  dysentery 
the  entire  colon  and  rectum  arc  involved,  but  in  this  event  the 

constitutional  disease  overshadows  the  affection  of  the  rectum. 
33 


514  DISEASES  OF  THE  RECTUM 

The  inflammation  of  the  rectum  is  generally  of  the  catarrhal 
variety,  but  in  chronic  cases  progresses  to  an  ulcerative  stage,  the 
ulcerations  being  linear,  punched-out,  and  like  little  grooves  in  the 
mucous  membrane  following  the  course  of  the  blood-vessels.  The 
purulent  discharge  is  very  profuse  and  the  submucosa  is  destroyed 
to  a  greater  extent  than  the  mucosa,  whence  the  undermined  edges 
of  the  ulcers. 

The  symptoms  of  the  acute  stages  of  dysenteric  proctitis  are 
pain  and  heat  in  the  pelvis  and  anal  region,  tenesmus,  diarrhea, 
slight  elevation  of  temperature,  rapid  pulse,  and  exhaustion.  The 
diarrhea  is  attended  by  the  frequent  painful  passage  of,  at  first, 
partly  solid  and  partly  fluid  stools,  changing  to  watery  stools  and 
finally  mucus,  tinged  with  blood  and  pus.  There  is  burning  after 
stool  and  the  frequency  of  defecation  is  very  great.  In  the  chronic 
stages  the  frequency  is  not  so  great  and  the  symptoms  are  those 
of  ulceration.  The  ulcers  have  the  characteristic  appearances  of 
worm-tracks  in  wood,  following  the  course  of  the  blood-vessels. 
They  sometimes  result  in  stricture. 


ABSCESS  AND  FISTULA  IN  ANO 

Abscess. — The  tissues  immediately  surrounding  the  anus  and 
rectum  are  especially  subject  to  infection  and  inflammation,  because 
of  the  abundant  lymphatic  and  blood  supply  of  the  parts,  from  the 
ample  source  of  bacteria  in  the  retained  contents  of  the  intestine, 
and  from  the  obstruction  to  the  circulation  caused  by  hardened 
fecal  masses. 

The  bacteria  most  frequently  found  in  abscesses  about  the 
rectum  are  the  tubercle  bacillus,  and  bacterium  coli  communis, 
generally  associated  with  staphylococcus  or  streptococcus. 

The  course  of  the  abscesses  is  acute  or  chronic,  only  the  deeper 
ones,  the  superior  pelvi-rectal  abscesses,  being  of  severe  grade  and 
immediately  dangerous  to  life.  Abscesses  in  this  region  burrow 
in  the  path  of  least  resistance,  passing  between  the  fascial  planes 
and  around  the  blood-vessels  which  are  large  enough  and  vigorous 
enough  to  resist  thrombosis  and  gangrene. 

Superficial  abscesses,  of  the  nature  of  acne  pustules  or  furuncles, 
open  on  the  skin;  subcutaneous  abscesses  and  deeper  seated 


ABSCESS 


515 


suppurations,  generally,  besides  opening  through  the  skin,  make 
their  way  between  the  internal  and  external  sphincters,  perforate 
the  mucous  membrane,  and  discharge  into  the  anal  canal,  forming, 
in  a  large  majority  of  cases,  a  fistula. 

Those  that  enter  the  bowel  alone  form  blind,  internal  fistulse, 
while  those  that  open  both  on  the  skin  and  into  the  gut  are  complete 
fistulae. 

The  different  sorts  of  abscesses  in  this  region  as  enumerated  by 
Goodsall  and  Miles  (  "Diseases  of  the  Rectum,"  Part  I.)  are:  —  (a) 
subcutaneous,  (6)  ischio-rectal,  (c)  submucous,  (d)  pelvi-rectal, 


•G'rcuhr  m 

Lorvitli^inoH  mvscfe  fibres- 
pelv/-re<foj  space. 

Levafor  anl. 


— Integument 
"Tendinous  insertion  of  the 


The  inferno) 

Interval between  the  infernal 
and  the  external  sphincTers 

Superficial  portion  of  the 
exferna)  sphincter    ~~  ^** 

Deep  portion  ojthe  exTerna]  sphincter. 

FIG.  195. — Diagrammatic  Representation  of  the  Lower  part  of  the  Rectum 
and  its  Immediate  Surroundings.     (After  Goodsall  and  Miles.) 

(e)  labial.    As  has  been  said,  the  (6)  ischio-rectal  abscess  opens  not 
only  on  the  skin,  but  also  between  the  sphincters  into  the  bowel. 

The  (c)  submucous  abscess  originates  in  the  submucous  tissue, 
usually  in  the  lowest  three  inches  of  the  rectum,  and  is  generally 
confined  to  one  side  of  the  bowel.  It  shows  a  tendency  to  burrow 
downward  and  to  empty  near  the  anus.  The  (d}  pelvi-rectal  abscess 
begins  in  the  loose  connective  tissue  between  the  levatores  ani 
below,  and  the  reflection  of  the  peritoneum  above.  This  space  being 
continuous  with  the  bases  of  the  broad  ligaments,  septic  inflamma- 
tory processes  starting  in  these  structures  may  spread  to  the 
pelvi-rectal  space.  Infection  may  come  from  the  rectum,  from 
malignant  disease  of  the  bowel,  or  ulcerations  high  up.  Rarely, 
in  the  acute  form  of  this  disease,  the  pus  may  rupture  through  the 


516  DISEASES  OF  THE  RECTUM 

peritoneum  into  the  abdominal  cavity;  in  the  chronic  forms  it  is 
more  apt  to  perforate  the  levators  and  form  an  ischio- rectal  abscess. 
This  sort  of  abscess  is  the  cause  of  deep  horseshoe  fistula.  The 
disease  is  generally  attended  by  extensive  cellulitis.  (e)  Labial 
abscess  is  an  extension  backward  to  the  anal  region  of  a  vulvo- 
vaginal  abscess.  This  is  a  rare  sort  of  abscess. 

The  symptoms  of  abscess  are  pain  in  the  rectum,  with  aching  and 
throbbing  especially  on  defecation,  tenderness  in  the  region  of  the 
anus,  and  constitutional  symptoms  in  the  acute  stages.  Exami- 
nation shows  great  heat,  tenderness,  and  induration  of  the  tissues, 
with  fluctuation  at  the  seat  of  the  abscess.  The  exact  situation  is 
determined  almost  entirely  by  palpation  and  the  physician  will 
search  for  the  different  sorts  of  abscesses  according  to  the  descrip- 
tions just  given. 

Fistula. — The  word  fistula  is  derived  from  the  Latin  fistula, 
something  capable  of  being  split,  a  hollow  reed  or  pipe.  Fistula 
in  ano  may  be  defined  as  an  unobliterated  abscess  track  which 
opens  cither  in  the  skin  near  the  anus,  or  into  the  rectum,  or  both. 
Fistula  is  comparatively  rare  in  women,  the  average  age  at  which 
it  occurs  being  thirty-six  years.  It  may  be  caused  by  a  fissure,  by 
ulceration  of  the  bowel,  by  stricture,  by  polypoid  growths,  or  by 
carcinoma. 

As  implied  by  the  definition,  an  abscess  always  precedes  a  fistula, 
except  in  the  very  rare  cases  of  fistula  caused  by  traumatism. 
A  fistula  generally  opens  by  one  orifice  in  the  bowel,  but  by  several 
in  the  skin. 

VARIETIES. — There  are  three  sorts  of  fistula),  although  all  three 
may  be  combined  in  the  same  patient.  They  are  (1)  complete, 
when  there  is  an  opening  through  the  skin  and  also  an  opening  into 
the  bowel,  and  (2)  incomplete,  including  (a),  blind  external,  when 
there  is  an  opening  into  the  skin  alone,  and  (&),  blind  internal, 
when  the  only  opening  is  into  the  rectum. 

1.  In  the  complete  fistula  the  main  track  generally  passes  between 
the  two  sphincters  into  the  rectum,  but  it  may  be  subcutaneous 
throughout,  and  not  go  round  the  external  sphincter. 

From  the  main  track  branches  go  off  to  end  in  blind  passages  or  to 
perforate  the  skin.  Rarely  the  main  sinus,  after  burrowing  between 
the  sphincters  toward  the  mucous  membrane  of  the  rectum,  may 
ascend  above  the  internal  sphincter  before  perforating  into  the 


FISTULA 


517 


rectum,  but  as  a  rule  the  internal  opening  is  in  the    anal  canal 
between  the    sphincters.     Complete  fistula?  form  about'  seventy 
per  cent  of  all  fistula?. 
2.  Of  incomplete  fistuloz  (a),  the  blind  external  fistula  is  an  abscess 


FIG.  196. — Diagram  of  Complete  Fistula  in  Ano. 

cavity  having  an  opening  in  the  skin,  near  the  anus.  The  track 
may  represent  a  previous  existing  complete  fistula  the  internal  open- 
ing of  which  has  closed.  In  the  case  of  (6),  the  blind  internal 
fistula,  there  are  three  courses  taken  by  the  abscess  track  to  its 
opening  into  the  bowel:  it  may  be  subcutaneous  and  pass  outside 


filt'ncl  infernal 
fitfula,  • 


FIG.  19(>a. —  Diagram  of  Blind  Internal  Fistula. 

the  external  sphincter  into  the  anus;  it  may  be  submuscular,  passing 
through  the  external  sphincter,  or  between  the  internal  and  the 
external  sphincters;  or  it  may  be  submucous,  coursing  entirely  in 
the  submucous  tissue.  The  last  form  is  often  due  to  a  preexisting 


518  DISEASES  OF  THE  RECTUM 

fissure,  is  apt  to  be  higher  in  the  rectum  than  the  others,  and  may  be 
felt  by  a  finger  in  the  rectum  as  a  cord,  running  in  the  rectal  wall. 

Goodsall  and  Miles  have  observed  that  fistula?  which  have 
started  posterior  to  a  transverse  line  drawn  through  the  anus,  bur- 
row more  extensively  than  those  that  have  started  in  front  of 
this  line. 

SYMPTOMS  OF  FISTULA. — The  symptoms  of  fistula  are  pus  from 
the  bowel,  together  with  the  history  of  a  preexisting  abscess,  or 
fissure,  or  other  rectal  disease.  Flatus  may  escape  from  a  complete 
fistula  and  also  liquid  feces  and  gas  may  distend  a  blind  fistula  so 
that  it  is  painful.  If  the  swelling  due  to  inflation  is  of  considerable 
size  it  is  possible  to  obtain  tympany  on  percussion.  The  pain  of 
fistula  is  inconsiderable  and  bleeding  is  only  an  occasional  symptom. 

PHYSICAL  EXAMINATION. — Examination  will  reveal  the  presence 
of  an  external  or  an  internal  opening,  or  both;  the  course  and 
ramifications  of  the  track  of  the  fistula,  and  the  presence,  or  absence, 
of  complicating  diseases. 

If  the  abscess  preceding  the  fistula  has  been  opened,  the  opening 
in  the  skin  is  apt  to  be  smaller  than  when  the  abscess  has  opened 
spontaneously.  All  the  openings  should  be  investigated  thor- 
oughly with  a  probe.  The  internal  opening  is  found  by  proctoscopy 
and  by  passing  a  probe  into  it  through  the  proctoscope.  Palpation 
and  the  passage  of  the  probe  are  the  main  reliances  of  diagnosis. 
Internal  piles  are  the  commonest  local  complication  of  fistula; 
fissure,  ulcer,  stricture,  polypi,  or  carcinoma  may  also  coexist. 

If  there  is  suspicion  that  a  fistula  is  tuberculous,  scrapings  of  tis- 
sue should  be  examined  for  the  tubercle  bacillus  rather  than  rely  on 
evidences  of  tuberculosis  elsewhere  in  the  body.  A  tuberculous 
fistula  has  generally  a  discharge  that  is  small  in  quantity  and  thin 
and  white,  and  the  fistula  is  surrounded  by  much  induration. 


STRICTURE  OF  THE  RECTUM 

Strictures  of  the  rectum  may  be  classified,  according  to  their 
causation,  as  congenital,  as  due  to  pressure  on  the  rectum  from 
without,  or  as  inflammatory.  Obstruction  of  the  lumen  of  the 
rectum  by  new  growths  of  the  rectum  or  by  foreign  bodies  in  the 
gut  may  be  disregarded  in  a  discussion  of  stricture,  as  may  the 


STRICTURE  OF  THE  RECTUM  519 

so-called  spasmodic  stricture,  which  was  formerly  thought  to  be 
very  prevalent,  but  is  now  regarded  by  writers  on  diseases  of  the 
rectum  as  a  rare  curiosity  and  a  temporary  condition.  Strictures 
may  be  further  classified,  according  to  their  form,  as  annular,  or 
as  tubular. 

Congenital  strictures  are  generally  found  in  the  anal  canal,  either 
at  the  margin  of  the  anus  or  just  below  the  level  of  the  internal 
sphincter.  The  condition  of  stricture  is  apt  to  be  regarded  as  simple 
constipation  and  the  patient  does  not  consult  the  physician  until 
puberty  or  after.  There  is  no  history  of  an  inflammatory  or  ul- 
cerative  process  of  the  rectum  and  a  careful  sifting  of  the  evidence 
shows  only  a  gradually  increasing  constipation.  The  stricture  may 
consist  of  a  band,  or  of  a  circular  membrane  with  an  opening  in  the 
center,  being  entirely  distinct  from  the  sphincter  muscle,  which 
may,  or  may  not,  be  hypertrophied.  Congenital  hypertrophy  of 
Houston's  valves  may  constitute  a  virtual  stricture. 

Strictures  due  to  pressure  on  the  rectum  from  without  are  relatively 
common  in  women,  as  in  the  retroversion  of  an  enlarged  or  gravid 
uterus,  or  a  tumor  wedged  in  the  pelvis,  or  a  pelvic  inflammatory 
exudate.  The  rectum  is  surprisingly  tolerant  of  interference  of 
this  sort  and,  beyond  a  constipation  and  a  mild  proctitis,  there 
may  be  no  evidences  that  the  caliber  of  the  bowel  is  very  nearly 
shut  off.  As  a  rule  the  symptoms  due  to  the  encroaching  body 
overshadow  those  due  to  obstruction  of  the  rectum. 

Inflammatory  Strictures. — These  constitute  a  majority  of  all 
strictures  and  are  due  to  tuberculous  ulceration,  to  syphilitic  ulcera- 
tion,  and  to  ulceration  of  unknown  origin.  Most  of  them  are  situated 
not  higher  than  two  and  a  half  inches  (6  centimeters)  from  the 
margin  of  the  anus.  Occasionally  a  stricture  of  this  sort  is  found 
as  high  as  three  and  a  half  inches  (9  centimeters)  up  the  bowel. 

Pathology  of  Inflammatory  Strictures. — Ulceration  of  the  mucous 
membrane  is  the  macroscopic  appearance  in  the  early  stages  of 
inflammatory  stricture.  When  the  ulceration  has  healed  there  is 
a  lack  of  elasticity  of  the  rectal  wall  and  it  has  a  dry,  leathery  feel 
and  a  dull,  non-shining  appearance.  Often  the  ulcerative  process 
continues  after  the  stricture  has  been  formed,  and  in  this  case  the 
rectum  contains  muco-purulent  discharge.  If  cicatrization  has 
taken  place,  the  cicatrix  appears  as  a  bluish-white,  dense,  liga- 
ment ous  structure.  The  ulcer  is  of  the  type  of  infection  causing  it; 


520  DISEASES  OF  THE  RECTUM 

that  is,  syphilitic,  tuberculous,  or  simple.  Syphilitic  ulceration  is 
apt  to  heal  below,  while,  at  the  same  time,  it  extends  upward. 
Gummata  may  be  found  in  the  course  of  the  arteries  and  veins, 
together  with  endarteritis.  In  the  tuberculous  stricture,  the  entire 
epithelial  surface  of  the  mucous  membrane  is  destroyed  and  caseous 
nodules  are  found  in  the  tissues  of  the  submucosa. 

Symptoms  of  Inflammatory  Strictures. — The  symptoms  of  stricture 
during  the  ulcerative  stage  are  dull,  constant  pain  in  the  region  of 
the  rectum,  diarrhea,  tenesmus,  and  the  discharge  of  mucus,  pus, 
and  blood;  during  the  obstructive  stage  they  are,  increased  fre- 
quency in  a  desire  for  an  action  of  the  bowels,  the  passing  of  small 
quantities  of  feces  with  incomplete  relief,  and,  after  an  interval 
of  a  few  minutes,  the  repetition  of  the  desire  for  defecation.  As 
the  stricture  becomes  smaller  in  caliber  the  feces  are  passed  in 
small-sized,  round,  or  flattened  pieces,  and,  if  ulceration  is  still 
present,  pus  or  blood  may  streak  the  stools. 

In  the  case  of  strictures  of  long  standing  the  large  intestine 
becomes  chronically  distended  because  of  insufficient  emptying, 
and,  as  a  result,  the  abdomen  is  distended.  The  patient  complains 
of  distention  and  of  flatulence,  more  particularly  during  the  first 
two  hours  after  taking  food.  Another  symptom  in  these  cases  is 
swelling  of  the  feet  and  legs,  particularly  on  the  left  side,  and,  in 
extreme  cases,  emaciation,  with  cachexia  from  autointoxication, 
result. 

Physical  Examination. — Physical  examination  shows  the  anus 
to  be  normal  in  appearance,  except  that  there  may  be  present 
several  folds  of  redundant  skin,  or  scars,  if  the  patient  has  suffered 
with  complicating  fistula.  If  the  stricture  happens  to  be  at  the 
anal  orifice,  the  natural  ruga?  are  absent  and  there  is  no  redundancy, 
while  cicatricial  tissue  takes  the  place  of  some  of  the  skin  at  the 
anal  margin.  Straining  on  the  part  of  the  patient  produces  bulging, 
but  no  relaxation  of  the  anus,  and  the  finger  feels  a  rigid  ring  about 
the  opening.  In  the  case  of  stricture  within  the  rectum,  the  finger 
introduced  into  the  rectum  notes  deficient  contractile  power  of 
both  sphincter  muscles.  The  stricture,  as  has  been  said,  is  generally 
in  the  lowest  two  and  a  half  inches  of  the  gut.  If  the  finger  tip 
will  pass  through  the  stricture,  the  caliber  and  the  shape  and 
length  of  the  stricture  may  be  estimated;  if  not,  the  finger  in  the 
vagina  will  estimate  the  length  of  the  inflammatory  or  cicatricial 


PROLAPSE  OF  THE  RECTUM  521 

mass.  The  short  proctoscope  passed  through  the  anus  permits 
a  view  of  the  stricture,  and  its  size  and  length  may  be  determined 
by  passing  through  it  olive-pointed  bougies.  Sometimes  a  smaller 
proctoscope,  or  a  large  Kelly  cystoscope,  may  be  passed  through 
the  stricture  and  a  view  of  the  rectum  beyond  the  stricture  thus 
obtained.  The  presence  of  much  thickening  about  the  rectum, 
with  the  escape  of  pus  on  digital  examination,  generally  indicates 
the  coexistence  of  an  ischio-rectal  or  pelvi-rectal  abscess. 

In  making  the  diagnosis,  the  history  should  be  inquired  into 
minutely  and  search  made  for  the  stigmata  of  syphilis  or  tubercu- 
losis, the  two  most  common  causes  of  stricture. 


PROLAPSE  OF  THE  RECTUM 

By  prolapse  of  the  rectum  is  meant  the  eversion  of  a  part  or  the 
whole  of  the  rectum  through  the  anal  orifice.  It  is  partial  when  the 
mucous  membrane  alone  is  everted,  and  complete  when  all  the 
coats  of  the  rectum  are  involved.  The  disease  is  found  most  fre- 
quently in  young  children  and  in  old  women,  especially  in  the 
women  who  have  suffered  from  weakening  of  the  sphincter  ani 
muscle  from  childbearing.  Laxity  of  the  connections  of  the 
mucosa  with  its  underlying  structures  and  weakening  of  the  tone 
of  the  sphincter  muscle  are  predisposing  causes.  Exciting  causes 
are  obstinate  constipation  and  chronic  diarrhea,  causing  prolonged 
and  repeated  straining  at  stool,  also  extruded  rectal  polypi,  or 
other  rectal  tumors,  causing  overstretching  and  relaxation  of  the 
sphincters. 

Symptoms. — The  symptoms  are  (a)  loss  of  control  over  the 
bowels  with  the  involuntary  escape  of  rectal  mucus  as  well  as 
flatus  and  feces;  (6)  protrusion  of  the  bowel,  at  first  at  stool  only, 
followed  by  spontaneous  reposition,  then  protrusion  on  coughing, 
or. any  sort  of  straining,  and,  finally,  permanent  prolapse  unless 
reduced  manually;  (r)  increased  frequency  in  the  action  of  the 
bowels ;  (rf)  pain  of  moderate  or  small  amount  as  a  result  of  long- 
continued  irritation — pain  is  of  an  aching  or  throbbing  character 
and  persists  as  long  as  the  part  is  protruded;  (e)  hemorrhage  when 
the  prolapsed  mucous  membrane  is  excoriated  or  ulcerated,  not 
of  large  amount  in  anv  case. 


522  DISEASES  OF  THE  RECTUM 

Physical  Examination. — The  prolapse  may  involve  the  entire 
circumference  of  the  rectum  or  only  a  part  of  it.  There  is  no 
redundant  skin  about  the  anus  in  these  cases  and  palpation  deter- 
mines that  the  mucosa  moves  freely  on  the  muscular  coat:  the 
sphincters  are  relaxed  and  deficient  in  contractile  power.  The 
determination  of  the  thickness  of  the  wall  of  the  prolapsed  mass 
shows  whether  only  the  mucous  membrane  or  the  entire  rectal  wall 
is  down.  If  the  mucosa  alone  is  extruded — incomplete  prolapse — 
the  mass  is  seldom  more  than  two  inches  long,  and  one  side  is  gen- 
erally longer  than  the  other.  In  complete  prolapse  the  protrusion 
is  generally  equal  on  all'  sides  and  the  mass  measures  some  three 
or  four  inches  in  length.  In  incomplete  prolapse,  the  opening  into 
the  lumen  of  the  gut  is  circular,  or  oval,  and  centrally  situated, 
whereas  in  complete  prolapse  the  opening  is  slit-like  and  points 
backward  because  of  the  traction  of  the  meso-rectum.  In  incom- 
plete prolapse  these  are  generally  sulci  anteriorly  and  posteriorly 
and  the  mucous  membrane  is  smooth,  whereas  in  complete  prolapse 
there  are  no  sulci  and  the  mucous  membrane  is  marked  by  several 
concentric  furrows. 

NEW  GROWTHS  OF  THE  RECTUM 

New  growths  of  the  rectum  are: — (1)  benign,  or  (2)  malignant. 

1.  BEXIGX  TUMORS  OF  THE  RECTUM  AND  ANUS 

Benign  tumors  are  of  infrequent  occurrence,  are  of  slow  growth, 
they  do  not  infiltrate  the  surrounding  structures,  and,  when  re- 
moved, do  not  show  a  tendency  to  recur.  They  may  be  divided  into: 
(a)  tumors  about  the  anus,  and  (6)  tumors  of  the  rectum. 

a.  Benign  Tumors  about  the  Anus 

These  are  papilloma,  soft  fibroma,  and  lipoma.  They  arise  from 
the  skin  and  subcutaneous  tissue. 

Papilloma. — Papilloma  is  due  to  hypertrophy  of  the  papillary 
layer  of  the  true  skin.  It  occurs  in  young  adults  and  appears  to  be 
due  to  want  of  cleanliness.  The  tumor  consists  of  an  enlarged  papilla 
in  the  form  of  a  bulb-shaped  tumor  about  half  an  inch  or  three- 
quarters  of  an  inch  long,  at  the  margin  of  the  anus.  Several  tumors 


NEW  GROWTHS  OF  THE  RECTUM  523 

are  generally  present  in  the  same  case  and  the  pedicle  of  each  is 
separated  from  its  fellow  by  a  strip  of  normal  skin.  Each  tumor 
is  made  up  of  a  central  artery  and  vein  in  a  connective-tissue 
stroma,  which  is  covered  by  stratified  epithelium.  The  surface  of 
the  papilloma  is  the  same  color  as  the  surrounding  skin,  though  it 
may  become,  eroded  and  ulcerated.  These  simple  tumors  must 
be  differentiated  from  carcinoma.  In  the  latter  there  is  no  normal 
skin  between  the  different  parts  of  the  tumor,  and  there  is  much 
infiltration  of  the  surrounding  skin  and  subcutaneous  tissues. 
Condylomata  lata  have  the  appearances  described  on  page  512 
and  condylomata  acuminata  those  to  be  found  on  page  407.  Hem- 
orrhoids are  of  a  deep  purple  color,  and  are  soft  and  compressible, 
or,  if  thrombosed,  very  hard. 

Soft  Fibroma. — Soft  fibroma  is  a  pedunculated  tumor  of  rare 
occurrence  arising  from  the  connective  tissue  of  the  submucosa.  It 
contains  besides  connective  tissue,  muscular  and  glandular  tissue, 
and  is  similar  in  structure  to  molluscum  fibrosum.  The  tumor  may 
attain  great  size  and  may  weigh  as  much  as  a  pound  or  more. 

Lipoma. — Lipoma  is  a  fatty  tumor  caused  by  hypertrophy  of 
one  or  more  lobules  of  fat.  It  is  situated  under  the  skin  surrounding 
the  anus,  is  soft,  and  is  freely  movable,  in  this  respect  being  dis- 
tinguishable from  an  inflammatory  exudate  or  abscess.  Occasionally 
a  lipoma  is  pedunculated. 

6.  Benign  Tumors  of  the  Rectum — Polypi 

These  tumors  originating  in  the  rectum  are  generally  pedunculated 
growths  and  therefore  are  classed  as  polypi.  They  are  of  the 
following  pathological  varieties:  adenoma,  fibroma,  myoma, 
villous  tumor,  myxoma,  and  lipoma. 

Adenoma. — Adenoma  or  mucous  polyp  is  the  most  common  form 
and  is  mot  with  almost  entirely  in  children  under  ten  years  of  age. 
It  consists  of  a  hypertrophy  of  the  crypts  of  Lieberkuhn,  and 
shows  on  section  the  tubules  lined  with  columnar  epithelium  and 
surrounded  by  areolar  tissue.  If  the  connective-tissue  elements 
predominate  the  tumor  becomes  a  fibre-adenoma.  Lymphoid 
tissue  may  form  the  basis  of  a  tumor  of  this  sort,  due  to  hyper- 
trophy of  one  of  the  solitary  follicles  of  the  rectum,  and  in  this 
case  the  tumor  is  a  lymphadenoma. 


524  DISEASES  OF  THE  RECTUM 

(flandular  polypi  arc  usually  single,  vary  in  size  from  a  quarter  of 
an  inch  to  one  inch  in  diameter,  are  round,  and  attached  to  the  rectal 
wall  by  a  long  and  slender  pedicle.  They  generally  arise  in  the  lowest 
two  inches  of  the  rectum  and  may  exist  for  a  long  time  before  the 
pedicle  becomes  enough  elongated  so  that  the  tumor  is  passed 
through  the  anus  at  defecation.  When  it  is,  the  diagnosis  may  be 
made.  The  probability  is  that  many  of  these  growths  are  torn  from 
their  pedicles  and  extruded  during  a  movement  of  the  bowels. 
The  symptoms  arc  hemorrhage  from  the  anus  after  the  growth 
has  gotten  within  the  grasp  of  the  sphincters,  and  straining.  The 
passage  of  blood  from  the  rectum,  in  children,  should  always  lead 
the  physician  to  make  a  rectal  examination.  The  examining  finger 
is  swept  around  the  rectum  and  search  made  for  the  pedicle  of  the 
tumor.  A  view  of  the  rectum  and  the  tumor  may  be  obtained 
through  a  Kelly  proctoscope,  No.  12.  To  make  an  accurate  diag- 
nosis an  anesthetic  will  generally  be  necessary. 

Fibroma  or  Fibrous  Polyp. — A  fibrous  polyp  is  generally  situated 
in  the  lowest  two  inches  of  the  rectum ;  it  is  from  a  quarter  of  an 
inch  to  an  inch  in  diameter,  and  is  attached  to  the  rectal  wall  by 
a  short,  thick  pedicle.  It  occurs  in  adults  and  is  usually  single. 
It  is  made  up  of  fibrous  tissue  and  is  covered  with  stratified  epithe- 
lium when  it  springs  from  the  anal  canal,  but  has  a  complete 
mucous  membrane  over  its  surface  if  it  originates  higher  up  in  the 
rectum.  The  tumor  originates  from  the  submucous  connective 
tissue,  a  thromboscd  internal  pile,  or  from  the  nodules  on  the  free 
edges  of  the  valves  of  Morgagni,  and  is  at  first  sessile. 

There  may  be  no  symptoms  until  the  growth  becomes  pedun- 
culated,  and  then  there  will  be  rectal  irritation  or  loss  of  blood. 
Digital  examination  will  detect  the  polyp  and  its  situation.  If 
the  pedicle  has  been  torn  by  the  violent  action  of  the  sphincter, 
there  may  be  so  much  pain  that  an  anesthetic  may  be  necessary 
before  a  satisfactory  diagnosis  can  be  made. 

Myomatous  Polyp. — Myomatous  polyp,  a  very  rare  sort  of  tumor, 
has  the  same  characteristics  as  fibrous  polyp,  except  that  the  tumor 
is  made  up  of  muscular  tissue  in  excess  of  fibrous  tissue. 

Villous  Tumor. — This  rare  sort  of  tumor  in  the  rectum  is  de- 
scribed by  Allingham  ("Diseases  of  the  Rectum")  as  "a  tabulated, 
spongy  mass,  with  long,  villus-like  groups  studding  its  surface." 
Goodsall  and  Miles  had  collected  thirty-five  cases  of  villous  tumors, 


NEW  GROWTHS  OF  THE  RECTUM  525 

twelve  in  their  own  experience.  The  tumors  appear  to  originate  en- 
tirely from  the  mucous  membrane  of  the  upper  rectum  in  patients 
who  are  beyond  middle  life.  The  growth  is  at  first  sessile  and  as  it 
increases  in  size  becomes  pedunculated,  the  pedicle  being  band-like 
or  poorly  developed.  If  it  is  well  developed  the  tumor  has  the 
appearance  of  being  slung  to  the  rectal  wall  as  by  a  mesentery, 
attached  obliquely.  These  tumors  do  not  infiltrate  the  rectal 
wall,  but  may  be  the  seat  of  carcinomatous  degeneration.  The 
symptoms  consist  of  the  escape  from  the  anus  of  a  thin,  watery 
fluid.  The  frequent  defecation  caused  by  the  tumor  is  described 
as  diarrhea.  There  may  be  present  dull  pains  in  the  region  of  the 
rectum  and  hemorrhage,  also  constipation  alternating  with  diarrhea, 
and  cachexia  from  loss  of  blood.  The  growth  itself  does  not  appear 
to  bleed  unless  it  is  prolapsed  through  the  anus.  Internal  piles 
are  apt  to  complicate  the  disease.  Anesthesia  and  the  rectal  specu- 
lum will  be  necessary  in  order  to  map  out  the  situation,  size,  and 
character  of  the  pedicle  of  a  villous  growth. 

Myxomatous  Polyp. — Myxomatous  polyp  is  very  rare  in  the 
rectum.  A  tumor  made  up  of  a  combination  of  fibrous  tissue  and 
mucoid  tissue,  a  fibro  myxoma,  is  occasionally  seen.  Here,  there 
are  loose  areolar-tissue  spaces  filled  with  a  thick  viscid  fluid.  The 
diagnosis  is  made  as  in  the  other  forms  of  benign  rectal  tumors. 
There  are  no  characteristic  symptoms  beyond  an  increasing  diffi- 
culty in  emptying  the  bowel  satisfactorily. 

2.  MALIGNANT  TUMORS 

Malignant  tumors  of  the  rectum  are  cancer  and  sarcoma,  the 
former  being  frequent,  and  the  latter  rare. 

Cancer  of  the  Rectum 

Cancer  of  the  rectum  forms  about  five  per  cent  of  cancers  of 
all  parts  of  the  body  (combined  statistics  of  45,906  cancers  by 
Heimann,  Zeman,  Kronlein,  and  De  Bovis,  "Diseases  of  the 
Rectum,"  J.  P.  Tuttle)  and  about  fifty  per  cent  of  all  cancers  of 
the  intestine  (same  statistics).  The  disease  is  more  frequent  in 
men  than  in  women  and  is  found  most  often  between  the  forty- 
fifth  and  fifty-fifth  years  in  both  sexes,  although  it  may  occur  at 
any  age.  The  etiology  is  entirely  unknown,  except  that  it  is  found 


526  DISEASES  OF  THE  RECTUM 

more  often  in  patients  who  have  suffered  previously  with  hemor- 
rhoids, ulceration,  or  benign  tumors  of  the  rectum. 

The  most  frequent  situation  of  the  disease  is  the  upper  rectum 
between  the  sigmoid  flexure  of  the  colon  and  the  internal  sphincter. 
The  lower  down  in  the  rectum  the  disease  is  situated  the  greater 
the  discomfort  to  the  patient  and  the  greater  the  likelihood,  there- 
fore, of  an  early  diagnosis. 

Cancer  of  the  Anus 

Cancer  of  the  anus  is  infrequent.  It  may  originate  in  the  skin 
about  the  anus,  in  this  case  being  a  squamous-celled  carcinoma, 
or  in  the  anal  canal  with  downward  extension,  an  adeno-carcinoma. 
Squamous-celled  carcinoma  is  rare  and  is  most  often  met  with  in 
women  over  fifty  years  of  age.  An  ulcer  having  an  indurated  base, 
bleeding  easily,  and  extending  into  the  margin  of  the  anus  is  the 
appearance  generally  seen. 

The  lymphatic  glands  in  the  groin  are  the  ones  that  are  enlarged 
in  cases  of  cancer  about  the  anus.  A  piece  of  the  ulcer  and  its  base 
should  be  removed  for  microscopic  examination. 

Pathology  and  Course. — Pathologically,  cancer  of  the  rectum 
belongs  to  the  class  of  adeno-carcinomata,  the  disease  showing 
an  atypical  growth  of  glandular  elements.  If  the  connective- 
tissue  elements  predominate  and  the  stroma  is  large  in  amount 
and  dense,  the  tumor  is  called  scirrhus;  if,  on  the  contrary,  the 
glandular  elements  predominate  and  the  tumor  is  soft  in  consist- 
ency it  is  called  medullary.  Colloid  degeneration  may  affect  the 
growth;  then  it  is  known  as  colloid  cancer. 

In  the  early  stages  adeno-carcinoma  of  the  rectum  is  a  sessile, 
rounded  tumor,  flattened  on  top,  situated  in  the  mucous  and  sub- 
mucous  tissues  and  freely  movable.  As  the  tumor  increases  in 
size  the  cancerous  outgrowths  invade  the  muscular  \vall  below, 
and  the  mucous  membrane  above,  so  that  within  a  few  months 
the  tumor  is  ulcerated  on  top,  fixed  in  the  rectal  wall,  and  of 
irregular  outline.  This  is  the  condition  usually  found  when  cancer 
of  the  rectum  in  an  early  stage  is  first  seen  by  the  physician, 
although  the  less  fully  developed  growth  is  occasionally  detected 
during  a  routine  examination. 

Involvement  of  the  lymphatic  glands  in  the  hollow  of  the  sacrum 
appears  to  be  a  relatively  early  event. 


CANCER  OF  THE  RECTUM  527 

The  cancerous  ulcer  is  excavated,  with  irregular,  everted,  and 
indurated  edges,  Jying  on  a  base  that  is  of  a  porky  hardness.  When 
it  has  extended  nearly  round  the  circumference  of  the  bowel 
stricture  occurs,  and  by  this  time  infiltration  of  the  tissues  sur- 
rounding the  rectum  takes  place  and  the  rectum  is  fixed.  The 
ulceration  may  open  into  the  vagina,  bladder,  or  peritoneum  in 
the  late  stages  of  the  disease,  and  at  this  time  the  abdominal 
lymph  glands  are  affected,  and  metastatic  deposits  occur  in  the 
liver  and  other  organs. 

Symptoms. — Goodsall  and  Miles  have  analyzed  with  great  care 
the  histories  of  their  cases  of  cancer  of  the  rectum,  with  a  view  to 
detecting  any  symptoms,  however  slight,  that  may  excite  the 
attention  of  the  physician  and  suggest  a  probable  diagnosis  of  this 
dreadful  disease.  The  patient's  condition  is  so  uniformly  hopeless 
in  the  later  stages  that  any  facts  that  may  lead  to  early  diagnosis 
must  be  sought  with  painstaking  assiduity. 

In  the  earliest  stages  before  ulceration  has  taken  place,  the  patient 
is  apt  to  complain  of  a  well-marked  attack  of  constipation,  having 
previously  had  regular  movements  without  the  use  of  laxatives; 
also  there  may  be  slight  loss  of  weight,  and  after  the  attack  of 
constipation  is  over  there  is  frequency  in  the  action  of  the  bowels 
excited  especially  by  the  ingestion  of  hot  fluids.  The  bowels  at  this 
time  may  act  four  or  five  times  during  the  day  and  not  at  all  at 
night.  Goodsall  and  Miles  insist  that  such  a  train  of  symptoms, 
occurring  in  women  who  have  passed  forty  years  of  age,  should 
lead  to  a  thorough  rectal  examination,  and  I  can  not  but  agree 
with  them,  for  any  tyro  can  make  a  diagnosis  in  the  advanced 
stages  when  it  is  too  late  for  treatment  to  be  of  avail,  and  the 
patient's  only  hope  lies  in  early  detection. 

When  the  ulcerative  stage  has  been  reached  the  symptoms  are, 
increased  frequency  of  defecation  with  difficulty  of  procuring  a 
satisfactory  evacuation  of  the  rectum,  the  appearance  of  blood  and 
mucus  in  the  stools,  pain  in  the  rectum  from  constant  straining, 
and  progressive  loss  of  weight. 

In  the  later  stages,  when  the  rectum  has  become  fixed,  the 
symptoms  are,  the  escape  of  blood,  mucus,  and  pus  without  feces, 
deep-seated  pain  in  the  pelvis,  over  the  sacrum,  and  extending 
down  the  thighs,  and  general  cachexia. 

If  there  is  stricture  nearly  occluding  the  lumen  of  the  rectum 


528  DISEASES  OF  THE  RECTUM 

the  symptoms  are,  obstinate  constipation  alternating  with 
diarrhea,  intermittent  hemorrhage,  pain  in  the  rectum  and 
also  in  the  abdomen,  abdominal  distention,  emaciation,  vomit- 
ing, and  obstruction.  The  odor  of  cancer  in  the  later  stages  is 
characteristic. 

Diagnosis. — The  diagnosis  is  founded  on  the  symptoms  and  on 
the  physical  examination.  The  latter  shows  the  anus  relaxed, 
patulous,  and  darker  than  the  surrounding  skin,  probably  caused 
by  obstruction  to  the  venous  circulation  and  constant  straining. 
The  usual  situation  of  the  disease  has  been  referred  to;  the 
anal  canal  will  be  found  free  from  disease.  With  the  aid  of 
the  finger  and  the  proctoscope  an  accurate  conception  must 
be  obtained  of  the  situation,  size,  color,  consistency,  and  shape 
of  the  lesion. 

The  growth  bleeds  easily  on  the  slightest  touch,  therefore  digital 
examination  will  be  followed  by  hemorrhage. 

Palpation  of  the  glands  in  the  hollow  of  the  sacrum  is  practiced 
by  turning  the  right  forefinger  with  its  palmar  surface  toward 
the  sacrum  and  feeling  on  both  sides  of  the  rectum  for  enlarged 
glands  in  that  situation.  The  inguinal  glands  should  be  investi- 
gated also,  especially  if  the  disease  is  situated  near  the  anus,  and 
in  late  stages  of  the  disease  secondary  deposits  in  the  liver  or  other 
organs  should  be  sought  for. 

Differential  Diagnosis. — The  following  conditions  must  be  ex- 
cluded:— Tuberculous  ulccration,  extensive  inflammatory  exudatc 
about  a  blind  internal  fistula,  polypi,  villous  tumor,  simple  stricture, 
and  gumma. 

Tuberculous  ulceration  in  the  rectum  is  rare.  It  is  attended  by 
no  distinct  tumor,  the  ulceration  does  not  bleed  easily,  its  base  is 
relatively  soft,  and  its  edges  arc  not  indurated.  Tubercles  and 
cheesy  matter  appear  in  the  granulations  of  the  floor  of  a  tubercu- 
lous ulceration  and  the  surrounding  induration  is  less  in  amount 
than  in  cancer.  The  microscope  will  show  the  presence  of  the 
tubercle  bacilli. 

Extensive  inflammatory  exuclate  about  a  blind  internal  fistula  will 
present  the  mucous  membrane  covering  the  induration  intact, 
except  where  the  fistula  opens;  the  tumor  is  smooth  in  outline, 
there  is  a  history  of  the  discharge  of  pus,  and  digital  examination 
produces  a  sudden  gush  of  pus  accompanied  by  a  diminution  in 


SARCOMA  OF  THE  RECTUM  529 

the  size  of  the  swelling.  Treatment  of  the  fistula  is  followed  by 
relief  of  the  symptoms. 

Polypi. — Adenomatous  or  mucous  polypi  occur  almost  exclu- 
sively in  children  under  ten  years  of  age.  The  surface  of  the  growth 
is  soft,  it  is  seldom  of  great  size,  and  is  protruded  at  stool.  The 
other  sorts  of  polypi  are  discrete  rounded  tumors  without  indu- 
ration surrounding  them. 

Villous  tumor  has  a  broad  obliquely  attached  pedicle,  it  is  soft 
and  velvety  to  the  feel,  and  is  lobulated.  It  may  cause  as  many 
as  twelve  actions  of  the  bowels  in  twenty-four  hours  and  it  rarely 
bleeds  unless  prolapsed. 

Simple  stricture  has  a  firm,  even  margin.  It  may  be  situated  at 
the  apex  of  an  invagination  of  the  rectum.  There  is  absence  of 
irregularity  and  induration  of  the  tissues  surrounding  the  stricture. 
The  bleeding  that  follows  a  digital  examination  is  always  slight 
in  amount  and  there  is  a  purulent  discharge. 

Gumma  of  the  rectum  is  very  rare.  There  is  a  history  of  syphilis. 
The  growth  is  round  and  smooth  and  elastic,  and  the  mucous  mem- 
brane over  it  is  healthy.  A  gumma  may  become  softened  and 
fluctuate.  Iodide  of  potash  given  by  the  mouth  will  cause  a  diminu- 
tion in  the  size  of  the  gumma. 

Sarcoma  of  the  Rectum 

Sarcoma  of  the  rectum  is  a  disease  of  later  life  and  occurs  in 
growths  of  three  pathological  varieties: — spindle-cell,  small  round- 
cell,  and  giant-cell,  any  one  of  which  may  take  on  a  melanotic 
change,  converting  the  tumor  into  a  melanotic  sarcoma. 

The  tumors  are  single  or  multiple,  they  vary  in  size  from  half 
an.  inch  in  diameter  to  the  size  of  an  orange,  and  they  are  situated 
generally  in  the  lowest  two  inches  of  the  rectum.  To  the  touch 
they  are  round,  of  irregular  surface,  and  relatively  hard  in  con- 
sistency, being  especially  dense  in  the  case  of  the  fibro-sarcomata. 
They  appear  of  the  color  of  the  normal  mucous  membrane,  but  may 
be  of  a  dark  red  or  grayish  color,  or,  in  the  melanotic  kind,  black. 
If  there  is  more  than  one  tumor  the  different  tumors  may  not  be 
alike  in  color. 

Sarcomas  of  the  rectum  grow  much  more  rapidly  than  do  car- 
cinomas, the  lymphatic  glands  being  involved  relatively  early. 
Metastas.es  occur  early  also. 

34 


530  DISEASES  OF  THE  RECTUM 

The  symptoms  of  sarcoma  arc  not  characteristic.  The  disinte- 
grating tissues  have  no  characteristic  odor.  The  attachment  of  a 
sarcoma  to  the  wall  of  the  rectum  does  not  spread  out  like  car- 
cinoma, it  is  abrupt  and  clearly  defined,  and  only  in  the  late  stages 
does  it  infiltrate  the  walls  extensively. 

Any  rapid  growing  tumor  of  the  rectum  should  be  removed  at 
once,  and  the  microscope  will  make  the  diagnosis. 


CHAPTER  XXVII 

THE  DIAGNOSIS  OF  DISEASES  OF  THE  BREAST 

Anatomy,  p.  532. 

Age  changes,  p.  534 :  The  infantile  breast,  p.  534.  The  breast  at  puberty, 
p.  535.  Lactation  hypertrophy,  p.  535.  The  senile  breast,  p.  536. 

Classification  of  diseases  of  the  breast,  p.  536. 

Anomalies,  p.  538:  Complete  absence  of  the  breast,  p.  538.  Incomplete 
development  of  the  breast,  p.  538.  Supernumerary  mammae,  p.  538. 

Symptomatic  lesions,  p.  539.  Pain,  areas  of  induration,  phantom  tumors, 
p.  539. 

Hypertrophies,  p.  539:  Infantile  hypertrophy,  p.  539.  Galactocele,  p. 
539.  Diffuse  bilateral  hypertrophy,  p.  540.  Senile  parenchymatous 
hypertrophy,  p.  540. 

Inflammations,  p.  542:  Mastitis,  p.  542;  Acute  mastitis,  p.  542;  Mammary 
abscess,  p.  542;  Submammary  abscess,  p.  542.  Chronic  mastitis,  p.  543; 
Chronic  interstitial  mastitis,  p.  543;  Diffuse  mastitis,  p.  543;  Lobular 
mastitis,  p.  542;  Tuberculous  mastitis,  p.  543;  Actinomycotic  and  syphilitic 
mastitis,  p.  544. 

Benign  tumors,  p.  544:  Fibro-epithelial  tumors,  p.  544.  Epithelial  tumors, 
p.  545. 

Malignant  tumors,  p.  545:  Carcinoma,  p.  545;  Adenocarcinoma,  p.  546; 
Comedo,  p.  546;  Colloid,  p.  546;  Cystic,  p.  546;  Intra-cystic  papillomatous 
varieties,  p.  546;  Medullary  carcinoma,  p.  546;  Scirrhous  carcinoma,  p.  548; 
Cancer  cysts,  p.  548;  Paget's  disease  of  the  nipple,  p.  548,  Sarcoma,  p.  549. 

Diagnosis  of  tumors  of  the  breast  in  general,  p.  549:  History,  p.  550. 
Age,  p.  550.  Duration  of  the  tumor,  p.  551.  Situation  of  the  tumor,  p.  551. 
Mobility  of  the  tumor,  p.  552.  Inspection  and  palpation,  p.  552.  Dimpling 
of  the  skin,  p.  552.  Retraction  of  the  nipple,  p.  553.  Enlarged  glands  in 
the  axilla,  p.  553.  Late  signs  of  cancer,  p.  553;  Discharge  from  the  nipple, 
p.  553;  Ulceration  of  the  skin,  p.  553;  Skin  metastases,  p.  553;  Metastases 
in  other  organs,  p.  553;  Enlarged  supraclavicular  glands,  p.  554;  Cachexia, 
p.  554;  Inadvisability  of  making  exploratory  incisions,  p.  554. 

ALTHOUGH  diseases  of  the  breast  are  commonly  regarded  as  in  the 
province  of  the  surgeon,  the  breasts  are  distinctly  a  part  of  woman's 
reproductive  apparatus  and  in  intimate  relationship  through 
the  nervous  system  with  the  uterus,  as  attested  by  the  uterine 
contractions  induced  by  suckling,  by  the  development  of  the 
breasts  and  their  functions  coincident  with  the  growth  of  the 
uterine  organs,  even  under  abnormal  conditions,  by  the  sexual 

531 


532  DISEASES  OF  THE  BREAST 

feelings  caused  by  manipulation  of  the  breasts,  and  finally,  by 
the  swelling  and  pain  in  the  breasts  associated  with  menstruation 
in  the  case  of  uterine  disease;  therefore  we  shall  discuss  here  the 
diagnosis  of  the  diseases  of  the  mamma?. 


ANATOMY 

The  breasts  consist  of  racemose  glandular  structures  situated 
beneath  the  skin  one  on  each  side  of  the  sternum.  Each  gland 
appears  as  a  hemisphere  projecting  from  the  front  of  the  thorax 
under  the  skin  and  covering  a  portion  of  the  pectoralis  major  and 
a  smaller  portion  of  the  serratus  magnus  muscles.  The  breast 
extends  from  the  level  of  the  second  rib  above  to  the  level  of  the 
sixth  rib  below,  and  laterally  from  the  margin  of  the  sternum  to 
the  axillary  line.  The  various  lobes  and  lobules  of  which  the  gland 
is  composed  radiate  from  the  nipple  and  extend  to  unequal  dis- 
tances in  different  parts  of  the  breast,  sometimes  forming  a  pro- 
longation of  the  gland  tissue  into  the  axilla,  over  the  serratus 
magnus  muscle,  or  toward  the  sternum.  In  the  rare  event  of  the 
occurrence  of  supernumerary  mamma:1  the  glands  are  found  on  a 
line  drawn  from  the  anterior  margin  of  the  axilla  downward  through 
the  nipple  over  the  flank,  the  so-called  "milk  line."  (See  Fig. 
200.) 

The  nipple,  cylindrical  in  shape  and  about  half  an  inch  in 
diameter,  projects  about  half  an  inch  from  a  point  a  little  below 
and  to  the  median  side  of  the  summit  of  the  hemisphere.  Its 
top  is  made  rough  by  fissures  and  in  the  center  is  a  depression 
in  which  arc  the  openings  of  the  milk  ducts. 

Surrounding  the  nipple  is  the  areola,  a  circle  of  pigmcnted, 
wrinkled  skin,  in  which  are  sweat  glands  and  from  a  dozen  to  twenty 
little  elevations  formed  by  the  sebaceous  glands. 

The  mammary  gland  rests  loosely  upon  the  pectoral  fascia,  so 
loosely  that  the  entire  breast  is  freely  movable.  A  sagittal  section 
of  the  mamma  shows  it  to  be  made  up  of  gland  tissue,  all  the 
ducts  of  which  converge  at  the  nipple;  of  fat,  fibrous  tissue,  and 
skin.  The  gland  tissue  is  firm  in  texture  and  of  a  pale  reddish 
color.  There  are  from  fifteen  to  twenty  excretory  ducts,  each  one 
coming  from  a  lobe,  every  duct  having  a  spindle-shaped  dilatation 


ANATOMY 


533 


as  a  reservoir  for  milk  just  before  it  emerges  from  the  apex  of  the 
lobe  into  the  nipple. 

The  lymphatic  glands  of  the  axilla  receive  the  greater  number 
of  the  lymphatic  vessels  of  the  breast  and  are  disposed  in  three 
groups:  the  pectoral,  at  the  outer  margin  of  the  pectoralis  muscle; 


PECTORALIS    MAJOR 


FIBROUS   SEPTUM 
GLAND    SUBSTANCE 

ADIPOSE    TISSUE 


FIRST 
RIB 


SECOND 

RIB 
PECTORALIS 

MINOR 

INTERCOSTALES 
SHEATH  OF  PEC- 
TORALIS MAJOR 


THIRD    RIB 


AREOLAR   TISSUE 


SUPERFICIAL 
FASCIA 


FOURTH    RIB 

LUNG 

ADIPOSE    TISSUE 
HORIZONTAL    PLANE 
OF    NIPPLE 


SIXTH    RIB 


FIG.  197. — Vertical  Section  of  Right  Breast,  Inner  Surface  of  Outer  Segment. 

(Testut.) 

the  axillary  proper,  in  the  loose  adipose  tissue  of  the  axilla;  and 
the  subscapular,  between  the  scapula  and  the  posterior  wall  of  the 
thorax.  The  anastomosis  of  the  lymphatics  of  the  breast  is  ex- 
ceedingly free  and  it  is  easy  to  see  how  the  skin  may  become  in- 
volved early  in  cancer  of  the  breast.  The  pectoral  group  of  axillary 
lymphatic  glands  is  the  one  usually  first  infected  in  this  disease. 


534  DISEASES  OF  THE  BREAST 


AGE  CHANGES 

The  Infantile  Breast. — The  breast  at  birth  consists  of  a  nipple 
covered  with  epidermis,  which  differs  from  normal  skin.  The 
mamma  is  surrounded  by  a  non-pigmented  areola.  On  section 
the  breast  is  seen  to  be  made  up  of  branching  ducts  surrounded 
by  loose  areolar  tissue  and  fat. 

Longridge,    who   studied    the    mammary   glands    of    still-born 


FIG.  198. — Dissection  of  the  Lower  Half  of  the  Breast,  Showing  the  Anatomical 
Arrangement  of  the  Milk  Ducts.     (Jewett.) 

infants.,  found  that  in  large  children  with  abundance  of  subcuta- 
neous fat  the  breasts  are  usually  well  developed,  irrespective  of  sex. 
The  breast  tissue  can  bo  felt  distinctly  as  a  solid  mass  lying  below 
the  primary  areola,  and  on  squeezing  it  a  fluid,  which  on  microscopic 
examination  is  indistinguishable  from  milk,  can  be  expressed. 
Whatever  the  cause  of  the  activity  of  growth  in  the  breast  of  the 
new-born  infant  may  be,  and  many  theories  have  been  advanced, 
such  as  the  existence  of  a  "chemical  messenger"  in  the  circulation, 


AGE  CHANGES 


535 


or  an  internal  secretion  from  the  maternal  placenta,  the  growth 
and  the  secretion  cease  soon  after  birth  and  the  breast  is  quiescent 
until  puberty  approaches. 

The  Breast  at  Puberty. — At  puberty  the  whole  breast  enlarges, 
the  nipple  becomes  larger  also,  and  is  more  sensitive;  the  areola 
increases  in  size  and  becomes  pigmented  to  a  moderate  degree  in 
brunettes.  Acini  lined  with  epithelium  are  formed  by  bulbous 
outgrowths  from  the  ducts,  and  there  is  an  increase  both  in  the 
gland  structures  and  the  intralobar  stroma. 

Lactation  Hypertrophy. — The  breasts  become  fuller,  the  veins  are 


FIG.  199. — Lymphatics  of  the  Left  Breast.     (Sappey.) 

prominent,  and  the  patient  has  a  sensation  of  swelling  of  the  breasts 
during  the  second  month  of  pregnancy  and  later.  The  nipples 
become  prominent  and  the  areola  pigmented.  In  the  wrinkled  skin 
of  the  latter,  the  enlarged  sebaceous  glands,  twelve  to  twenty  in 
number,  stand  up  as  little  elevations.  During  the  fifth  month 
there  appears  a  secondary  areola  outside  the  primary  areola, 
consisting  of  a  network  of  pigment  around  light  spots,  each  repre- 


53G  DISEASES  OF  THE  BREAST 

senting  a  circle  round  the  opening  of  a  sebaceous  gland.  Colostrum 
may  be  pressed  from  the  nipple  by  skillful  stroking  of  the  breast 
toward  the  areola  after  the  third  month  of  pregnancy.  The 
secretion  of  milk  is  not  established  until  the  end  of  the  second  day 
of  the  puerperium.  On  section  of  a  breast  during  lactation  one 
notes  that  the  gland  structure  is  enormously  hypertrophied,  the 
intralobular  connective-tissue  stroma  having,  to  all  intents  and 
purposes,  disappeared,  and  the  blood-vessels  and  lymphatics  are 
much  enlarged. 

The  Senile  Breast. — Atrophy  takes  place  early — between  thirty 
and  forty — in  the  case  of  women  whose  breasts  have  not  undergone 
lactation  hypertrophy.  In  the  latter  event  the  atrophy  begins 
with  the  onset  of  the  menopause.  The  gland  structure  shrinks, 
but,  if  the  woman  is  well  nourished,  fat  takes  its  place  and  the 
breast  may  retain  its  former  size.  When  senile  atrophy  is  well 
advanced  the  breast  consists  of  bands  of  fibrous  tissue,  with  oc- 
casional remains  of  a  duct  or  an  acinus  lined  with  atrophic  epithe- 
lial cells  surrounded  by  fat  and  radiating  from  the  nipple. 

CLASSIFICATION  OF  DISEASES  OF  THE  BREAST 

The  following  classification  is  taken  from  J.  C.  Bloodgood's 
excellent  article  on  diseases  of  the  female  breast  in  Kelly  and 
Noble's  "  Gynecology  and  Abdominal  Surgery,"  being  based  on  a 
clinical  and  pathological  study  of  1,048  lesions  of  the  breast, 
observed  in  the  surgical  pathological  laboratory  of  the  Johns 
Hopkins  Hospital. 

I.  Anomalies. 
II.  Symptomatic  Lesions. 

1.  Pain  (neuralgia  of  breast,  mastodynia). 

2.  Areas  of  congestion  (phantom  tumors). 
III.  Hypertrophies. 

1.  Infantile  (duct  ectasia). 

2.  Puberty  hypertrophy  (normal). 

3.  Lactation  hypertrophy  (physiological). 

4.  Diffuse  bilateral  hypertrophy  (pathological). 

5.  Senile  parenchymatous  hypertrophy,   with   and   without 

cvst  formation. 


CLASSIFICATION  537 

IV.  Inflammations  (Mastitides). 

1.  Pyogenic,  with  abscess  formation. 

(a)  Associated  with  lactation. 
(6)  Not  associated  with  lactation. 

2.  Chronic    interstitial,   with  parenchymatous     atrophy  and 

without  cyst  or  abscess  formation. 

3.  Tuberculosis. 

4.  Actinomycosis. 

5.  Syphilis. 

V.  Benign  Tumors. 

1.  Fibro-epithelial  tumors: 

(a)  Intracanalicular    myxoma  (periductal  myxoma  or 

fibroma-Warren) . 
(6)  Adenofibroma. 

2.  Epithelial  tumors: 

(a)  Adenoma  (cystadenoma). 

(6)  Cysts  with  intracystic  papilloma. 

(c)  Simple  cyst,  single  or  multiple  (see  senile  parenchy- 

matous hypertrophy). 

(d)  Galactocele  (see  lactation  hypertrophy). 

3.  Miscellaneous  rare  tumors: — lipoma,  enchondroma,  lymph- 

angioma,    dermoid    cysts,   calcium    deposits,    encysted 
foreign  bodies. 

VI.  Malignant  Tumors. 

1.  Carcinoma. 

(a)  Adenoca  cinoma. 
(6)  Medullary  carcinoma. 

(c)  Scirrhus  carcinoma. 

(d)  Cancer  cysts. 

2.  Sarcoma. 

(a)  Secondary  to  intracanalicular  myxoma. 
(6)  Non-indigenous. 

Let  us  now  consider  briefly  the  different  le  ions  of  the  breast 
that  figure  in  the  preceding  classification  before  proceeding  to 
a  clinical  diagnosis  of  tumors  of  the  breast  in  general  (see 
page  549). 


538  DISEASES  OF  THE  BREAST 


I.  ANOMALIES 

Complete  absence  of  the  breast,  usually  affecting  one  breast  only, 
has  been  described  as  a  very  rare  anomaly  and  is  due  to  lack  of 
development  in  early  embryonic  life.  Sometimes  the  ovary  on 
the  corresponding  side  is  absent  also. 

Incomplete  development  of  the  breast,  with  or  without  absence 
of  the  nipple,  is  much  more  common  than  absence  and  is  apt  to  be 
associated  with  anomalies  of  the  uterine  organs.  When  the  nipple 
is  wanting  the  areola  is  often  imperfectly  formed  or  absent  al- 
together. 

Supernumerary  mammae  are  not  very  rare.    They  are  usually  near 


FIG.  200. — The  "Milk  Line"  or  Situation  of  Supernumerary  Mammtr,  also  the 
B roust  Divided  into  Quadrants.     (Warren.) 

the  situation  of  the  normal  breast  or  in  the  "milk  line,"  (see  page 
532).  Garre  observed  five  developed  mammrn,  two  on  the  thorax, 
one  in  each  axilla,  and  one  in  the  median  line  below  the  ensiform 
cartilage.  Some  authorities  consider  that  seven  pairs  of  mammae 
existed  originally  in  the  human  race,  situated  in  the  "milk  line," 
three  above  and  three  below  the  present  normal  pair,  and  that 
supernumerary  breasts  indicate  a  return  to  a  primal  type. 

A  remarkable  case  has  been  reported  by  Blum  (Mimchen.  med. 
Wochenschr.,  May  21,  1907)  of  a  girl  seventeen  years  old  who  had 


HYPERTROPHIES  539 

two  well-developed  mamma?  in  the  normal  situation  and  a  third 
mamma  in  the  region  of  the  mons  vcneris  the  size  of  a  goose  egg  and 
surmounted  by  seven  nipples.  The  two  normal  mammae  had  no 
secretion,  but  four  of  the  seven  nipples  of  the  supernumerary 
breast  secreted  a  copious  amount  of  colostrum  regularly  just  before 
and  during  the  first  day  of  each  menstruation. 


II.     SYMPTOMATIC  LESIONS 

Pain  in  the  breast  associated  with  a  localized  swelling  is  not 
uncommon,  especially  in  young  childless  married  women  at  the 
time  of  menstruation.  The  painful  swelling  is  firm,  but  disappears 
when  menstruation  is  over.  Sometimes  gynecologists  see  areas  of 
induration  in  the  breasts  of  patients  with  uterine  disease.  In  a 
doubtful  case  of  a  tumor  which  has  existed  for  a  long  time  the 
patient  should  be  anesthetized  and  careful  palpation  will  show 
whether  the  tumor  is  a  pJiantom  tumor  or  not.  If  a  breast  tumor  is 
found  to  be  real,  the  wisest  course  is  to  remove  it  at  the  same  sitting, 
having,  of  course,  already  gained  the  patient's  consent,  and  have 
the  tumor  examined  by  the  pathologist.  Mammary  neuralgia 
may  be  due  to  pressure  on  the  breasts  from  badly  fitting  corsets, 
or  from  traction  in  the  case  of  excessively  pendent  breasts,  and  is 
commonly  observed  in  neurotic  women  at  the  time  of  menstruation. 
It  occurs  also  in  anemic  women  and  in  sexually  precocious  girls. 
Only  when  the  pain  is  present  in  one  breast  alone  does  the  symptom 
call  for  careful  investigation  of  the  breasts. 

III.   HYPERTROPHIES 

Infantile  hypertrophy  is  a  rare  affection  due  to  the  abnormal 
distention  of  the  ducts  with  desquamated,  degenerated  epithelium. 
The  breast  at  this  time  is  more  apt  to  become  infected  and  mas- 
titis ensues  often.  Ordinarily  the  swelling  of  the  breast  subsides 
spontaneously. 

Puberty  and  lactation  hypertrophy  have  been  considered  on  page 
535. 

Galactocele  is  a  cystic  tumor  occurring  during  lactation  and 
caused  by  the  dilatation  of  a  duct.  The  tumor  is  flask-shaped, 


540  DISEASES  OF  THE  BREAST 

with  the  mouth  of  the  flask  at  the  nipple.  Fluctuation  is  present 
and  the  .skin  and  nipple  are  normal.  In  some  cases  there  are 
several  of  these  tumors  in  a  breast.  Absence  of  inflammatory 
thickening  should  distinguish  a  galactocele  from  a  pyogenic  mas- 
titis. 

Diffuse  Bilateral  Hypertrophy. — Excessive  enlargement  of  the 
breasts  due  to  abnormal  growth  of  breast  tissue,  a  sort  of  adeno- 
fibroma,  found  mostly  in  young  unmarried  women,  is  always  a 
bilateral  disease.  The  increase  in  size  is  slow,  requiring  from  one 
to  fourteen  years  to  attain  a  considerable  development,  and  the 
enlargement  is  first  noticed  between  eleven  and  thirty  years  of  age. 
Occasionally  the  progress  of  these  cases  is  rapid,  as  in  the  one  re- 
ported by  Durston,  \vhere  the  two  breasts  weighed,  after  removal, 
sixty-four  and  forty  pounds,  respectively,  the  growth  having  taken 
place  within  four  months.  This,  I  think,  is  the  largest  case  on 
record. 

The  enlargement  begins  in  one  breast  and  after  a  time  the  op- 
posite breast  also  begins  to  grow.  The  breasts  are  at  first  full  and 
firm,  but  later  become  flaccid.  The  areolse  are  increased  in  diameter 
and  the  nipples  become  flattened  by  pressure.  The  great  bulk 
of  the  breasts,  which  may  reach  nearly  to  the  knees,  may  impede 
locomotion  or  even  interfere  with  respiration.  No  cases  of  cancer 
occurring  in  diffuse  bilateral  hypertrophy  have  been  recorded. 

Senile  Parenchymatous  Hypertrophy. — This  disease,  forming  a 
quarter  of  all  the  benign  lesions  and  occurring  during  the  cancer 
age,  is  the  most  important  of  the  non-malignant  tumors. 

The  etiology  is  not  known.  The  pathology  consists  of  an  increase 
in  the  parenchyma,  the  epithelial  cells  proliferating  and  degenerat- 
ing, associated  with  dilatation  of  the  ducts  and  acini, — an  adeno- 
matous  type.  In  the  early  stage  there  are  no  symptoms,  unless, 
possibly,  pain  and  tenderness  associated  with  areas  of  increased 
density  in  the  breast.  With  further  distention  of  the  ducts  cysts 
are  formed,  the  lining  epithelium  being  destroyed  in  the  course  of 
time,  or  the  dilated  ducts,  instead  of  being  filled  with  fluid,  contain 
proliferating  epithelial  cells, — the  adenocystic  type. 

If  one'  tumor  is  present  it  may  feel  like  an  area  of  induration 
without  definite  boundaries,  or  it  may  be  a  sharply  circumscribed 
growth,  in  the  latter  event  being  at  times  large  enough  to  involve 
an  entire  quarter  of  the  breast. 


HYPERTROPHIES  541 

Palpation  will  show  a  cystic  character  (the  cyst  being  generally 
spherical)  or  perhaps  a  simple  hard  area.  The  nipple  and  the  skin 
over  the  tumor  are  normal.  If  a  quadrant  of  the  breast  is  involved 
the  normal  contour  will  be  altered.  The  adenocystic  type  of  tumor 
grows  rapidly,  the  tumor  reaching  a  considerable  size  in  a  few  days, 
but  cases  are  on  record  where  the  growth  had  existed  for  several 


FIG.  201. — Diffuse  Bilateral  Hypertrophy  of  the  Breasts.     (Warren-Gould.) 

years.    There  may  be  a  discharge  from  the  nipple,  and  pain  is  a 

symptom  of  the  early  stages. 

If  there  are  two  or  more  tumors  present  in  one  or  both  breasts, 
the  diagnosis  is  made  by  finding  one  circumscribed  cystic  tumor 
and  several  smaller  shot-like  tumors,  generally  in  the  opposite 
breast. 

On  exploratory  section  a  cyst  has  thin  walls  with  smooth  inner 


542  DISEASES  OF  THE  BREAST 

surface  and  the  contents  arc  clear  and  fluid,  never  bloody,  or  thick 
as  in  the  case  of  a  cancer  cyst. 


IV.  INFLAMMATIONS— MASTITIS 

Mastitis  may  be  due  to  the  Staphylococcus  albus  or  aureus, 
to  the  tubercle  bacillus,  to  the  Spirocrueta  pallida  of  syphilis, 
and  very  rarely  to  the  actinomyces  bacillus.  It  is  (a)  acute,  or 
(b)  chronic. 

a.  Acute  mastitis  occurs  almost  without  exception  during 
lactation  and  generally  before  the  fourth  month  of  lactation.  It  is 
more  often  met  with  in  primiparae.  It  is  probable  that  infection 
reaches  the  gland  tissue  through  the  nipple  and  the  ducts  in  most 
cases,  but  may  get  there  by  way  of  the  blood  or  from  neighboring 
anatomical  structures. 

The  early  caking  of  the  breast  during  the  first  few  days  of  labor 
seldom  leads  to  abscess  formation.  At  any  time  after  this,  gen- 
erally in  the  first  four  weeks,  always  before  the  fourth  month  of 
lactation,  one  or  more  areas  of  induration  may  be  observed  in  one 
breast,  attended  by  a  rise  of  body  temperature,  a  chill,  and  pain 
and  tenderness  in  the  breast.  A  crack  in  the  nipple  is  often  to  be 
found  in  such  a  case.  Resolution  may  take  place  without  abscess 
formation  if  the  breast  is  properly  supported  and  passive  hypcremia 
induced  after  Bier's  method.  If  not,  a  mammary  abscess  results; 
the  indurated  area  becomes  reddened,  the  pain  increases  so  that 
nursing  is  impossible,  there  are  leucocytosis  and  a  constant  elevation 
of  temperature,  and  fluctuation  with  adhesion  of  the  skin  to  the 
indurated  mass  can  be  made  out. 

Abscesses  arc  apt  to  be  multiple  and  the  breast  may  be  riddled 
witli  them.  Sometimes  not  only  the  parenchyma  of  the  gland  is 
infected,  but  the  loose  connective  tissue  between  the  breast  and 
the  pectoral  muscle  is  involved  and  a  submammary  abscess  is  the 
result. 

The  important  point  in  diagnosis  is  to  recognize  the  beginning 
of  pus  formation,  so  that  an  early  incision  may  be  made;  and  thus 
obviate  destruction  of  breast  tissue,  sinuses,  and  a  prolonged  sup- 
puration with  its  deleterious  effects  on  the  system.  Therefore  the 
appearance  of  redness  of  the  skin  over  an  indurated  area  of  gland 


INFLAMMATIONS  543 

tissue,  a  union  of  the  skin  with  the  tissues  underneath,  continued 
elevation  of  temperature  and  leucocytosis,  are  indications  that 
pus  has  formed,  even  though  fluctuation  can  not  be  determined. 

A  rare  form  of  "acute  carcinoma"  or  " carcinomatous  mastitis" 
developing  rapidly  in  the  course  of  mastitis  has  been  described 
by  Volkmann. 

6.  Chronic  mastitis  includes  both  suppurative  and  non-sup- 
purative  inflammations  of  the  breast.  The  pyogenic  variety  may 
follow  an  acute  mastitis,  in  which  case  the  abscess  wall,  lined  with 
granulation  tissue,  becomes  thickened  and  the  pus  filling  the 
abscess  is  of  thin  consistency. 

Chronic  interstitial  mastitis  is  a  chronic  inflammation  of  the 
interstitial  connective  tissue  of  the  gland.  The  connective  tissue 
is  increased  in  amount  and  crowds  out  the  acini  and  ducts.  In 
the  later  stages  there  is  atrophy  of  all  the  structures  and  the 
breast  on  section  shows  a  dull  opaque  white  surface,  with  very  few 
of  the  pink  spots  of  secreting  gland  substance  to  be  seen.  The 
disease  may  be  limited  to  individual  lobules  of  the  mamma,  in 
this  case  being  referred  to  as  a  lobular  mastitis,  or  it  may  involve 
the  entire  gland — diffuse  mastitis. 

Chronic  interstitial  mastitis  is  found  in  women  of  middle  age 
in  the  non-lactating  breast,  it  has  no  distinctive  symptoms,  and 
must  be  differentiated  from  cancer. 

Chronic  mastitis  generally  affords  a  history  of  an  acute  attack 
of  mastitis  some  time  in  the  past,  the  lump  in  the  breast  has  been 
stationary  in  size  since  it  was  first  noticed,  it  is  painful,  and  more 
tender  than  cancer,  it  does  not  involve  the  surrounding  structures, 
either  muscle  below,  or  fat  and  skin  over  it,  and  the  tumor  is  freely 
movable. 

Tuberculous  mastitis,  forming  six  per  cent  of  all  benign  lesions 
of  the  breast,  is  a  form  of  chronic  mastitis  occurring  between  the 
ages  of  twenty-five  and  thirty-five,  and  occurring  more  often  in  the 
non-lactating  than  in  the  lactating  breast.  As  a  rule,  it  occurs 
after  the  fourth  month  of  lactation  and  is  unilateral. 

There  may  be  no  family  history  of  tuberculosis  and  there  may  be 
no  other  lesions  of  tuberculosis  elsewhere  in  the  body.  The  disease 
begins  in  an  area  of  induration,  generally  in  the  region  of  the 
areola.  The  induration  breaks  down  and  an  abscess  is  formed 
without  acute  symptoms  of  pain  and  fever,  the  abscess  ruptures 


544  DISEASES  OF  THE  BREAST 

spontaneously,  leaving  a  sinus.  At  this  time  an  exact  diagnosis 
may  be  made  by  means  of  the  microscopic  examination  of  tissue 
removed  from  the  abscess  or  sinus  wall. 

Actinomycotic  and  Syphilitic  Mastitis. — These  forms  of  mastitis, 
extremely  rare,  are  diagnosed  in  the  case  of  actinomycosis  by  the 
characteristic  appearance  of  the  tissues  (see  page  332).  In  the 
case  of  syphilis  a  primary  lesion  has  been  known  to  occur  on  the 
nipple.  It  has  the  characteristic  appearance  of  chancre  elsewhere 
(see  page  406).  Mucous  patches  have  been  observed  both  on  the 
nipple  and  in  the  folds  under  a  pendulous  breast.  Only  a  few  cases 
of  gumma  of  the  breast,  and  diffuse  syphilitic  mastitis  have  been 
described.  The  diagnosis  of  syphilis  rests  on  the  history  with  the 
definite  period  of  incubation  of  the  disease,  and  on  the  appearance 
of  the  lesions,  which  arc  the  same  as  in  the  vulva  (see  page  406). 

Search  should  be  made  for  the  spirochseta  pallida  in  excised 
tissue  or  the  discharges. 

It  is  thought  that  the  tissue  changes  resulting  from  lactation 
mastitis  furnish  a  predisposition  to  cancer  and  John  Speese  (An- 
nals of  Surgery,  Vol.  LI.,  Feb.  1910,  p.  212)  advises  removal  of 
all  indurated  areas  from  this  cause  occurring  in  the  breasts  of 
women  who  are  near  the  menopause. 

V.  BENIGN  TUMORS 

1.    FlBRO-EPITHELIAL  TUMORS 

These  arc  intracanalicular  myxomata  and  adenofibromata,  the 
former  being  the  more  common,  and  both  together  forming  39 
per  cent  of  333  benign  tumors  of  the  breast  observed  by  Bloodgood. 
The  tumors  are  single,  or  multiple  (in  about  one-fifth  of  the  cases), 
they  occur  in  one  or  both  breasts  and  in  young  women,  the  average 
age  at  which  they  are  first  noticed  being  less  than  twenty-five 
years. 

Cancer  has  never  been  observed  as  a  complication  of  this  sort 
of  tumor.  The  growth  is  slow.  Most  of  the  tumors  are  single  and 
small  and  may  be  removed  without  sacrificing  the  breast. 

Recurrence  of  a  tumor  of  the  fibre-epithelial  type  should  be 
regarded  as  an  instance  of  successive  tumors  developing  at  different 
periods  of  time  from  separate  foci,  rather  than  the  growth  of  a  new 


MALIGNANT  TUMORS  545 

tumor  from  elements  of  the  first  one,  and  as  these  tumors  are 
multiple  in  a  fifth  of  all  cases,  such  a  so-called  "recurrence"  might 
well  be  more  common  than  it  is.  As  a  matter  of  fact  these  "re- 
currences" are  very  rare. 

Large  intracanalicular  myxomata  sometimes  occur  in  older 
women — from  thirty  to  fifty  years  of  age.  These  have  a  tendency 
to  develop  into  sarcoma  and  therefore  call  for  a  radical  operation. 

The  adenofibroma  is  always  relatively  small  in  size,  is  spherical, 
hard  and  firm,  even  calcareous  in  some  instances;  the  older  the 
tumor  the  more  fibrous  tissue  is  present. 

2.  EPITHELIAL  TUMORS 

Cystic  Adenoma. — This  is  a  rare  form  of  growth  consisting  of  a 
small,  encapsulated,  freely  movable  tumor  occurring  in  breasts  of 
sterile  women  between  the  ages  of  thirty  and  fifty  years. 

Cysts  with  intracystic  papilloma  are  also  rare  and  constitute  a 
form  that  can  not  be  distinguished  clinically  from  malignant  cysts 
of  the  same  characteristics.  The  chief  symptom  of  the  benign 
cyst  is  a  discharge  of  blood  from  the  nipple.  The  cyst  is  generally 
single,  occurs  in  women  between  the  ages  of  thirty  and  sixty, 
and  its  growth  is  generally  slow.  On  account  of  the  impossibility 
of  making  an  exact  diagnosis,  such  a  cyst  should  be  removed 
together  with  the  entire  breast  and  the  pectoral  muscle  and  axillary 
glands. 

For  a  discussion  of  simple  cysts  and  galactocele  see  page  539. 


VI.     MALIGNANT  TUMORS 

CARCINOMA 

The  average  duration  of  life  in  cancer  of  the  breast  from  the 
first  time  the  tumor  is  noticed  until  death  is  3.77  years.  In  the 
case  of  atrophic  scirrhus  a  patient  has  been  known  to  live  over 
nine  years,  but  only  in  this  form  of  cancer  has  life  been  prolonged 
so  far.  The  disease  is,  then,  of  comparatively  slow  growth — nearly 
four  years  on  the  average — and  the  opportunities  for  early  diag- 
nosis and  removal  of  the  disease  are  therefore  ample. 

Cancer  of  1  lie  breast  maybe  divided,  for  the  purposes  of  diag- 


546  DISEASES  OF  THE  BREAST 

nosis,  into  the  following  varieties: — adenocarcinoma,  medullary 
carcinoma,  scirrhus,  and  cancer  cysts. 

Adenocarcinoma. — Adenocarcinoma  formed  14.4  per  cent  of  the 
carcinoma  cases  seen  in  Halsted's  clinic.  In  this  species  of  cancer 
the  inoperable  cases  were  the  fewest  and  the  percentage  of  cures 
greatest;  in  other  words,  the  disease  progresses  more  slowly  and 
involves  the  surrounding  structures  later  than  in  the  other  forms 
of  cancer.  Bloodgood  enumerates  four  varieties  of  adenocarcinoma, 
namely:  the  comedo,  or  duct  cancer;  the  colloid;  the  adenocystic ; 
and  the  malignant  intracystic  papilloma.  Each  may  be  pure,  or 
any  one  may  be  combined  with  medullary  or  scirrhous  cancer. 

Comedo  Adenocarcinoma. — This  is  the  commonest  type.  The 
cut  surface  of  a  breast  affected  with  this  disease  shows  trabecula? 
of  fibrous  tissue  in  the  meshes  of  which  are  round,  granular  areas 
from  the  center  of  which  worm-like  comedo  bodies  can  be  ex- 
pressed, the  appearance  being  characteristic.  The  tumor  has  no 
capsule.  The  disease  begins  as  a  small  circumscribed  tumor  and 
may  be  shot-like,  sometimes  being  multiple,  and  rarely  occurring 
in  both  breasts. 

Colloid  Adenocarcinoma. — This  differs  from  the  preceding  in 
having  a  thin  capsule,  and  presenting  on  section — bulging  between 
the  fibrous  trabecula? — pink  gelatinous  lobules  which  are  pathog- 
nomonic. 

Cystic  Adenocarcinoma. — This  may  be  either  circumscribed  or 
diffuse,  the  latter  occurring  generally  during  senile  parenchy- 
matous  hypertrophy.  The  disease  is  characterized  by  the  occurrence 
of  cysts  in  an  encapsulated  tumor  showing  on  section  the  char- 
acteristics of  adenoma.  Glandular  involvement  is  late  and  a 
permanent  cure  following  operation  may  be  expected,  even  if  the 
skin  and  muscles  are  involved. 

Adenocarcinoma  with  Papilloma  in  the  Cysts. — This  is  similar 
to  the  benign  form  (cystic  adenoma,  see  page  545)  except  that  the 
papilloma  proliferates  and  becomes  an  infiltrating  fungous  growth 
resembling  medullary  carcinoma. 

A  discharge  of  blood  takes  place  from  the  nipple  just  as  in  the 
benign  form,  the  only  difference  being  that  the  malignant  type 
infiltrates  and  the  fungous  growth  is  different  in  appearance  from 
the  benign  papilloma. 

Medullary  Carcinoma.— This  formed  three  per  cent  of  Halsted's 


MALIGNANT  TUMORS 


547 


cases  of  cancer.  It  grows  rapidly,  but  does  not  infiltrate  as  soon 
as  scirrhus.  It  is  the  form  of  cancer  most  often  found  in  the  lac- 
tating  breast.  Beginning  as  a  small,  circumscribed,  soft  tumor, 
it  soon  becomes  larger  and  begins  to  ulcerate.  On  section  the 
fibrous  stroma  may  be  seen  enclosing  much  granular,  friable  tissue, 
which  may  be  forced  out  on  pressure. 
This  form  of  cancer  is  frequently  associated  with  adenocarcinoma 


FIG.  202. — Scirrhous  Cancer  of  the  Left  Breast.     (Warren-Gould.) 

both  of  the  comedo  and  the  cystic  varieties.  There  is  one  type  of 
medullary  carcinoma,  called  the  hemorrhagic,  which  is  characterized 
by  the  occurrence  of  patches  of  old  and  fresh  blood  throughout 
the  tumor,  as  seen  when  a  section  is  made. 

Medullary  carcinoma  often  resembles  sarcoma  and  pathologists 
are  puzzled  to  differentiate  them. 


548  DISEASES  OF  THE  BREAST 

Scirrhous  Carcinoma. — Scirrhous  cancer  may  be  divided  into  the 
circumscribed,  the  small  infiltrating,  and  the  large  infiltrating  scir- 
rhus.  On  cutting  a  scirrhous  tumor  of  whatever  sort,  the  physician 
experiences  a  gritty  sensation  as  the  knife  goes  through  the  tough 
tissue  and  on  feeling  the  cut  surface  with  the  finger  it  is  lumpy  and 
hard.  To  the  eye  it  shows  much  white  fibrous  stroma  with  yellow 
dots  and  lines  in  the  interstices.  The  disease  infiltrates  the  surround- 
ing structures  relatively  early  and  has  all  the  marks  of  malignancy 
within  twelve  months  of  the  first  appearance  of  the  tumor.  Glan- 
dular involvement  and  metastases  to  other  organs  are  common. 

The  large  infiltrating  scirrhous  cancers  are  the  most  dangerous 
and  furnish  the  largest  proportion  of  the  inoperable  cases.  Ac- 
cording to  Bloodgood's  analysis  of  the  cases  in  Halsted's  clinic, 
70  per  cent  of  all  the  cancers  were  scirrhous,  and  of  these  10  per 
cent  were  circumscribed,  29  per  cent  were  large  infiltrating,  and 
31  per  cent  were  small  infiltrating  scirrhus. 

The  diagnosis  rests  on  the  presence  of  a  hard  tumor  presenting 
all  the  characteristics  of  malignancy  (see  page  552). 

Cancer  Cysts. — These  tumors  are  rare,  forming  only  2.7  per  cent 
of  all  tumors  of  the  breast.  The  diagnosis  from  benign  cyst,  before 
operation,  is  impossible. 

On  exploratory  incision  the  cancer  cyst  contains  blood,  but  no 
papilloma,  or  it  contains  a  thick,  grumous  material  formed  from 
broken-down  epithelial  cells.  A  galactocele,  on  the  other  hand, 
has  thin,  smooth  walls  and  is  surrounded  by  lactating  breast  tissue; 
a  circumscribed,  chronic  abscess  has  a  thick  wall  and  thin,  clear 
or  cloudy,  serous  contents;  a  papillomatous  cyst  generally  con- 
tains blood  and  papillomatous  material;  and  a  malignant  adeno- 
matous  cyst  has  an  infiltrating  fungous  growth  lying  in  bloody 
contents.  True  cancer  cysts  are  extremely  malignant  and  are 
generally  fatal,  whether  operated  upon  or  not. 

Paget's  Disease  of  the  Nipple. — Chronic  eczema  of  the  nipple 
associated  with  ulceration  of  the  nipple,  occurrng  in  women  between 
forty  and  sixty,  is  now  regarded  as  a  secondary  manifestation  of 
cancer  of  the  breast,  the  primary  lesion  being  a  malignant  tumor 
of  the  breast,  the  nipple  being  involved  by  metastases  along  the 
ducts  or  lymphatics.  Paget  described  the  disease  in  1874  and  until 
very  recently  the  lesions  of  the  nipple  and  areola  were  thought  to 
precede  the  formation  of  a  tumor  in  the  breast. 


DIAGNOSIS  OF  TUMORS  IN  GENERAL  549 


SARCOMA 

True  sarcoma  of  the  breast  is  rare.  Bloodgood  found  eighteen 
among  five  hundred  and  five  malignant  tumors.  It  occurs  as  pri- 
mary sarcoma  of  the  stroma  of  the  breast,  as  sarcoma  arising  in 
intracanalicular  myxoma,  and  as  metastatic  sarcoma  from  some 
other  organ.  The  primary  sarcoma  presents  on  section  soft, 
friable  tissue  lining  the  walls  of  cyst  cavities;  the  intracanalicular 
myxomatous  form  has  distinct  lobulations  and  the  characteristics 
of  myxoma. 

Sarcoma  shows  the  manifestations  of  malignancy,  the  patients 
are  between  the  ages  of  forty  and  fifty,  and  the  growth  of  the  tumor 
is  rapid. 

THE  DIAGNOSIS  OF  TUMORS  OF  THE  BREAST  IN  GENERAL 

The  importance  of  early  diagnosis  in  diseases  of  the  breast  can  not 
be  insisted  on  too  often.  The  operating  surgeons  constantly  see 
cases  where  the  probable  diagnosis  was  not  made  until  too  late 
and  as,  at  the  present  time,  the  only  hope  for  the  patient  with 
cancer  lies  in  its  early  removal,  delay  on  the  part* of  the  general 
practitioner,  who  sees  nearly  all  of  the  patients,  seals  the  death 
warrant.  In  this  connection  M.  H.  Richardson  says: — "The  evils 
of  wrong  diagnosis  need  not  be  exemplified,  but  the  evils  of  a  too- 
positive  opinion  do  need  emphasis,  especially  those  opinions  which, 
if  wrong,  sacrifice  health,  or  even  life  itself." 

W.  L.  Rodman,  from  a  large  operative  experience,  estimates 
that  it  is  impossible  to  make  a  diagnosis  of  cancer  in  an  operable 
stage  in  about  ten  per  cent  only  of  all  cases. 

In  other  words,  an  early  diagnosis  of  cancer  can  be  made  in 
ninety  per  cent  of  all  cases  of  cancer.  That  such  a  percentage 
does  not  obtain  at  present  we  have  only  to  glance  at  the  oper- 
ability  record  of  a  large  clinic,  such  as  Halsted's  at  the  Johns 
Hopkins  Hospital.  Of  464  patients  admitted  with  the  diagnosis 
of  primary  carcinoma  of  the  breast,  in  only  349,  or  75.3  per  cent, 
was  the  disease  in  an  early  enough  stage  of  development  to  permit 
of  a  radical  operation  at  the  hands  of  zealous  advocates  of  this  sort 
of  operating.  In  all  probability  the  percentage  would  be  much 


550  DISEASES  OF  THE  BREAST 

lower  among  less  enthusiastic  hospital  surgeons,  and  even  less 
among  general  practitioners. 

According  to  W.  L.  Rodman  the  three  most  important  points 
to  consider  in  the  diagnosis  of  a  tumor  of  the  breast  are,  the  age  of 
the  patient,  the  situation  of  the  growth,  and  whether  or  not  it  is 
adherent  to  the  surrounding  tissues. 

History. — The  history  that  malignant  tumors  have  occurred  in 
the  family  of  the  patient  may  occasionally  be  obtained,  but  in  at 
least  three-quarters  of  the  cases  the  family  history  is  negative  in 
this  respect.  This  is  the  case  also  in  tuberculosis  of  the  breast, 
forming  about  six  per  cent  of  the  benign  lesions  of  the  breast  and 
occurring  between  the  ages  of  twenty-five  and  thirty-five. 

The  history  of  syphilis  in  the  patient  may  point  toward  the 
very  rare  lesion,  gumma  of  the  breast,  and  the  fact  that  the  patient 
has  been  exposed  to  the  contagion  of  syphilis  might  lead  to  the 
detection  of  chancre  of  the  nipple,  an  unusual  disease. 

Injuries  or  blows  on  the  breast  were  formerly  thought  to  be 
causative  of  tumors.  Now  we  may  say  that  nothing  is  known  of 
the  etiology  of  tumors  except  that  the  inflammatory  lesions  follow 
infection,  which  may  sometimes  be  traced  by  the  history. 

Married  women  are  more  subject  to  breast  cancer  than  the  un- 
married, and  the  fruitful  more  than  the  sterile. 

The  date  when  the  tumor  was  first  noticed  must  be  carefully 
recorded,  also  whether  it  has  grown  larger,  and  the  amount  of  pain 
or  tenderness,  both  in  the  early  stages  of  the  tumor  and  during  the 
time  intervening  between  its  beginning  and  the  present  consultation. 

Age. — The  only  disease  of  the  breast  occurring  in  infancy  is  ab- 
normal distention  of  the  ducts  (duct  ectasia)  with  a  discharge  from 
the  nipple,  sometimes  associated  with  pyogenic  mastitis,  therefore 
the  breast  is  practically  immune  from  disease  until  the  hyper- 
trophy of  puberty.  At  this  time  and  after,  the  fibre-epithelial 
tumors  (adenofibroma  and  intracanalicular  myxoma)  may  occur. 
During  lactation  an  induration  is  generally  due  to  pyogenic  mastitis. 
Any  of  the  inflammations  may  occur  from  puberty  to  the  meno- 
pause, also  any  of  the  benign  tumors. 

Carcinoma  is  essentially  a  disease  of  the  atrophic  breast,  but  it 
may  occur  as  early  as  nineteen  (case  of  A.  J.  McCosh).  Only  a 
few  cases,  however,  have  been  reported  of  the  disease  occurring 
earlier  than  t went v- five. 


GI  f  rr_r 
DIAGNOSIS  OF  TUMORS   IN  GENERAL  .V,l 

/ •*  \J  ' s  r~  t  r-  '—  'J 

''  '  k/Cf/lffr   /.    ^ 

Rodman  analyzed  5,000  cases  of  cancer  of  the  breast,  with  refer- 
ence to  the  age  at  which  it  was  diagnosed,  and  found  that  a  fifth 
of  all  the  cases  occurred  in  women  under  40  years  of  age.  Almost 
an  equal  number  occurred  in  the  two  decades  between  40  and  50, 
and  between  50  and  60.  After  60,  cancer  of  the  breast  is  infrequent. 
Therefore  the  age  of  greatest  frequency  is  the  time  of  the  menopause 
and  the  succeeding  years  while  the  breast  is  undergoing  atrophic 
changes. 

Sarcoma,  forming  about  three  and  a  half  per  cent  of  all  malignant 
tumors  of  the  breast,  is  found  in  women  who  are  in  the  neighbor- 
hood of  40  years  of  age.  Bloodgood  puts  the  age  at  40  to  50, 
but  says  that  sarcoma  occurs  as  a  complication  in  intracanalicular 
myxoma,  which  commonly  is  found  in  younger  women.  This  may 
account  for  Gross'  earlier  statistics.  In  35  of  his  cases  of  "cystic 
sarcoma"  the  average  age  was  33.7  years,  and  in  60  cases  of  "solid 
sarcoma,"  only  13  were  in  women  over  40  years  of  age. 

Even  at  the  present  time  the  differentiation  of  sarcoma  from 
medullary  carcinoma  is  often  a  difficult  problem  for  the  patholo- 
gist, and  a  second  examination  of  the  specimen  not  infrequently 
brings  a  change  in  the  diagnosis. 

To  summarize,  if  the  patient  is  under  twenty-five  the  presump- 
tion is  that  a  given  tumor  of  the  breast  is  benign;  if  over  twenty- 
five  it  is  either  benign  or  malignant,  with  the  probability  of  the 
latter  increasing  as  the  age  of  the  patient  becomes  more  advanced. 

Duration  of  the  Tumor. — A  tumor  which  has  been  present  a  year 
or  more  and  yet  manifests  no  evidences  of  malignancy  (see  page  546) 
is  generally  benign;  still,  a  scirrhous  cancer  may  exist  for  as  long 
as  five1  years  without  involving  the  surrounding  tissues  to  an  ap- 
preciable extent. 

Situation  of  the  Tumor. — Cancer  is  more  frequently  found  in  the 
upper  and  axillary  side  of  the  breast,  although  it  may  be  found  in 
any  portion ;  next  in  point  of  frequency  is  the  region  of  the  areola. 
Malignant  tumors  in  this  situation  are  apt  to  pull  on  the  nipple 
and  cause  retraction  more  often  than  in  the  case  of  growths  situated 
in  the  outer  portions  of  the  gland. 

Benign  tumors  are  more  frequently  found  in  the  sternal  half  of 
the  breast,  and  are  very  rare  in  the  areola.  Mastitis,  with  the 
exception  of  the  tuberculous  form,  occurs  chiefly  in  the  outer, 
axillary  side. 


552  DISEASES  OF  THE  BREAST 

Cancer  generally  involves  one  breast  only,  but  has  been  found 
in  both  breasts  in  about  five  per  cent  of  all  malignant  tumors.  If 
a  benign  tumor  has  been  removed  from  one  breast,  another  tumor 
occurring  in  the  opposite  breast  would  probably  be  benign  also. 
As  a  rule,  multiple  tumors  are  benign. 

Mobility  of  the  Tumor. — Inspection  and  Palpation. — If  a  tumor 
is  freely  movable  and  not  adherent  to  the  skin  it  is  not  cancerous. 
If,  on  the  other  hand,  it  is  fixed  either  to  the  muscle  below  or,  more 
important,  to  the  skin,  causing  dimpling, — and  when  situated  in 
the  region  of  the  areola,  retraction  of  the  nipple, — the  growth  is 
almost  certainly  cancer.  To  determine  the  connection  of  the 
tumor  with  the  skin,  expose  both  breasts  fully,  place  the  palm  of 
each  hand  flat  on  the  center  of  each  breast,  and  move  the  breasts 
alike  to  and  fro  in  every  direction  until  asymmetry  is  produced  in 
the  diseased  one  by  the  adhesion  of  the  tumor  to  the  skin.  This 
procedure  is  especially  valuable  in  deep-seated  growths  in  large 
and  fatty  breasts. 

In  palpating  the  breast  a  malignant  growth,  if  it  has  reached  the 
surface,  is  hard  and  of  irregular  outline;  if  situated  deeply  its 
connection  with  surrounding  tissues  limiting  its  mobility  or  causing 
asymmetry  must  be  the  determining  diagnostic  features. 

If  the  nipple  is  retracted  it  should  be  seized  firmly  and  pulled  out, 
comparing  it  with  the  nipple  of  the  opposite  breast.  The  physician 
should  bear  in  mind  that  many  women  have  ill-formed  and  re- 
tracted nipples  from  birth.  Should  both  nipples  show  deformity 
the  patient  should  be  questioned  as  to  their  usual  shape. 

Atrophy  of  the  subcutaneous  fat,  even  if  the  tumor  is  not  actually 
connected  with  the  skin,  is  a  strong  indication  of  cancer. 

To  determine  any  union  between  the  tumor  and  the  subcutaneous 
areolar  tissue  or  the  reticular  layer  of  the  corium  some  surgeons 
pick  up  the  skin  over  the  tumor  and  thus  demonstrate  a  shortening 
of  the  fibrous  trabeculce  of  the  subcutaneous  tissue  or  corium, 
comparing  this  finding  with  the  condition  of  the  skin  elsewhere  in 
the  breast;  others  use  the  test  of  moving  both  breasts  about  as  just 
described.  Another  method  is  to  grasp  one  breast  with  both  hands, 
whereupon  the  skin  intervening  between  the  hands  will  show 
dimpling  if  cancer  is  present  and  a  smooth  bulging  surface  if  a 
benign  tumor  is  present. 

In  practising  inspection  and  palpation  the  physician  makes  a 


DIAGNOSIS  OF  TUMORS  IN  GENERAL  553 

mistake  if,  to  save  the  patient's  feelings,  he  does  not  expose 
thoroughy  both  breasts,  the  chest  being  in  a  good  light.  The 
slightest  amount  of  asymmetry  should  lead  to  a  thorough  investi- 
gation as  described  above. 

Retraction  of  the  nipple,  as  has  been  pointed  out,  is  a  sign  of 
cancer  in  the  early  stages  of  malignant  disease  situated  in  the 
neighborhood  of  the  areola. 

Enlarged  glands  in  the  axilla,  formerly  thought  to  be  an  important 
diagnostic  sign  of  cancer,  are  now  found  to  be  fairly  constant 
signs  of  benign  tumors  and  inflammations  of  the  breast. 

Pain  in  the  breast  is  a  common  symptom  of  the  last  two  lesions 
also,  and  appears  in  cancer  only  in  the  inoperable,  late  stages. 
Pain,  unassociated  with  tumor,  occurs  also  in  neuralgia  of  the 
breast  (mastodynia),  a  rare  condition  except  where  associated 
with  menstruation  or  the  menopause.  In  the  latter  event,  it  may 
be  due  to  senile  parenchymatous  hypertrophy.  Pain  in  the  region 
of  the  breast  may  be  due  to  rheumatism  of  the  pectoral  muscle. 
In  this  case  it  should  be  called  forth  by  abducting  the  arms  on  the 
chest. 

Late  Signs  of  Cancer. — Late  signs  of  cancer  interest  us  only  hi  so 
far  as  they  indicate  whether  or  no  the  disease  has  passed  a  stage 
where  operation  may  be  attempted  with  hope  of  a  favorable  result. 
They  are:  pain,  a  discharge  of  blood  from  the  nipple,  ulceration, 
skin  metastases,  metastases  in  other  organs,  enlarged  supraclavic- 
ular  glands,  and  cachexia. 

Discharge  from  the  Nipple. — Besides  being  found  in  late  cancer, 
a  discharge  from  the  nipple  is  present  in  the  following  conditions: — 
during  pregnancy  and  lactation,  in  the  infantile  breast,  in  senile 
parenchymatous  hypertrophy,  and  in  papillomatous  cysts.  In 
the  last  case  it  is  apt  to  be  bloody. 

Ulceration  of  the  Skin  over  the  Cancerous  Growth. — This  is  a  very 
grave  sign  and  few,  if  any,  patients  presenting  ulceration  have 
been  cured  by  operation. 

Skin  Metastases. — Occasionally  two  or  more  shot-like  bodies  are 
found  in  the  skin  of  the  breast  at  a  distance  from  the  malignant 
tumor.  These  are  metastases  from  the  tumor  and  are  of  serious 
import,  for  no  case  of  permanent  cure  where  skin  metastases  were 
present  has  been  reported. 

Metastases  in  other  Organs. — These  are  always  an  indication  of  the 


554  DISEASES  OF  THE  BREAST 

hopelessness  of  radical  operation.  M.  H.  Richardson  has  recently 
called  attention  (Jour.  Amer.  Med.  Assn.,  May  15,  1909,  Vol.  LIL, 
p.  1556)  to  the  importance  of  making  a  complete  physical  exami- 
nation in  the  case  of  mammary  cancer,  saying  that  he  has  twice 
opened  the  abdomen  for  abdominal  tumors  of  doubtful  diagnosis 
without  examining  the  breasts;  and  in  both  cases  there  were  ex- 
tensive cancerous  infiltrations,  which  were  metastatic  from  the 
breasts.  He  says  also  that  any  persistent  cerebral  or  spinal  symp- 
toms in  cancer  of  the  breast  should  lead  to  an  examination  of  the 
nervous  system  for  metastases  in  the  cerebro-spinal  axis,  of  which 
he  has  now  seen  many  cases;  and  a  persistent  cough  should  call 
for  an  examination  of  the  lungs  to  find  metastases  there. 

Enlarged  Supradavicular  Glands. — Palpable  enlarged  glands 
above  the  clavicle  are  of  grave  significance,  the  most  favorable 
statistics  showing  only  7.5  per  cent  of  cures  following  operation 
where  the  sign  had  been  present.  In  the  opinion  of  many  opera- 
tors, the  presence  of  these  enlarged  glands  places  the  patient  in 
the  list  of  the  hopeless. 

Cachexia. — When  the  disease  has  reached  the  point  where  the 
patient's  health  has  failed  and  anemia,  constipation,  anorexia, 
loss  of  strength,  a  yellow  color  of  the  skin,  and  other  symptoms 
of  derangement  of  bodily  function  are  present,  there  will  be  found 
also  metastases,  lack  of  mobility  of  the  tumor, — because  of  the  in- 
volvement of  surrounding  structures, — and  ulceration,  and  the 
prognosis  is  absolutely  bad. 

In  all  cases  of  clinically  doubtful  diagnosis,  it  is  not  wise  to  make 
an  exploratory  incision  into  the  tumor  with  the  knife,  or  the  hollow 
Mixter  punch,  because  of  the  very  great  danger  of  autoinfection. 

If  a  tumor  is  of  doubtful  diagnosis  it  should  be  removed,  the 
pathologist  in  attendance  at  the  operation  deciding,  by  means  of 
sections  of  the  tumor,  the  need  of  radical  extirpation  of  surrounding 
structures. 


CHAPTER  XXVIII 

THE  DIAGNOSIS   OF    THE  GYNECOLOGICAL  AFFECTIONS 
OF   INFANCY  AND  CHILDHOOD 

Importance  of  examining  the  genitals,  p.  555.     The  examination,  p.  556. 

Anomalies,  p.  557:  Adherent  prepuce,  p.  557.  Labial  hernia,  p.  558. 
Hydrocele  of  the  labium  majus,  p.  559.  Imperf orate  hymen,  p.  560.  Im- 
perf orate  rectum  and  anus,  p.  561.  Prolapse  of  the  uterus,  p.  562.  Erosion 
of  the  cervix,  p.  563.  Precocious  menstruation  and  precocious  maturity,  p. 
564. 

Diseases  of  the  vulva  and  vagina,  p.  566:  Vulvo-vaginitis,  p.  566;  Simple 
vulvo-vaginitis,  p.  566;  Gonorrheal  vulvo-vaginitis,  p.  566,  Symptoms, 
p.  568,  Diagnosis,  p.  568;  Tuberculosis  of  the  vulva,  p.  568;  Diphtheritic 
vulvitis,  p.  569.  Gangrene  of  the  vulva,  or  noma,  p.  569.  Sarcoma  of  the 
vagina,  p.  570. 

Genital  hemorrhages,  p.  571 :  Hemorrhage  from  the  vulva  in  the  new- 
born, p.  572.  Hemorrhage  from  the  vulva  in  little  girls,  p.  572. 
Metrorrhagia  of  puberty,  p.  573. 

Masturbation,  p.  574. 

Malignant  disease  of  the  uterus,  p.  576. 

Diseases  of  the  ovaries  and  tubes,  p.  576:     Diagnosis,  p.  576. 

Diseases  of  the  bladder,  p.  578 :  How  to  collect  the  urine  in  infants,  p.  578. 
Peculiarities  of  urination,  p.  578.  Enuresis,  p.  578.  Bacteriuria,  p.  579. 
Cystitis  and  stone  in  the  bladder,  p.  581.  Primary  tumor  of  the  bladder,  p. 
.58-2.  Hematuria,  p.  583. 

Diseases  of  the  rectum,  p.  584 :  Prolapse  of  the  rectum,  p.  584.  Proctitis, 
p.  585.  Fissure  in  ano,  p.  585.  Incontinence  of  feces,  p.  585. 

WITH  the  march  of  progress  the  gynecological  affections  of  chil- 
dren that  were  formerly  thought  to  be  so  infrequent  as  to  merit 
little  attention,  are  now  known  to  be  not  only  not  rare,  but  of  con- 
siderable importance  from  the  standpoint  of  prophylaxis,  if  from 
no  other.  Practically  all  the  diseases  found  in  the  adult  have  now 
been  observed  in  children.  It  is  a  well-known  fact  that  the  genitals 
of  the  female  infant  are  not  so  carefully  looked  after  by  the  physician 
and  nurse  as  are  those  of  the  male  child.  Abnormalities  of  the 
prepuce  in  the  latter  are  almost  always  noted,  while  the  vulva  of 
the  little  girl  is  not  systematically  inspected.  Neglect  of  abnor- 
malities and  disease  in  the  female  infant — such,  for  instance,  as  an 
insufficient  opening  in  the  hymen,  adhesions  of  the  nymphae,  or 
vulvo-vaginitis — provide  in  later  years  for  retained  menses,  or  in- 

555 


556 


INFANCY  AND  CHILDHOOD 


fcction  of  the  genital  tract,  enuresis,  masturbation,  or  salpingitis,— 
or  for  uterine  malpositions,  which  are  the  result  of  previous  pelvic 
peritonitis.  The  relatively  frequent  occurrence  of  sarcoma  of  the 
vagina  in  infants,  its  rapid  and  fatal  course,  make  delay  in  diagnosis 
especially  dangerous.  Also,  diseases  of  the  urinary  organs  are  by 
no  means  rare  and  deserve  prompt  attention. 


EXAMINATION 

The  examination  of  the  genital  organs  in  children  varies  from 
that  in  adults  in  that  the  anatomical  parts  are  very  much  smaller 
and  the  little  patient's  attention  has  to  be  distracted  and  her  good- 
will obtained  in  greater  measure  before 
the  investigation  can  be  carried  through. 
The  use  of  an  anesthetic  becomes  neces- 
sary more  often  in  the  case  of  children 
than  in  adults,  in  order  to  secure  the 
essential  relaxation.  A  digital  examina- 
tion of  the  vagina  should  seldom  be  at- 
tempted in  children.  If  the  vagina  is 
to  be  examined  it  must  be  inspected 
through  a  Kelly  cystoscope  of  the  largest 
size  that  will  enter  the  vagina  without 
rupturing  the  hymen ;  artificial  light  and 
a  head  mirror  being  employed  as  de- 
scribed in  the  chapter  on  the  investiga- 
tion of  the  bladder  (Chapter  VIII.,  page 
110).  The  knee-chest  position  is  the 
best  posture  for  the  examination.  (See  Fig.  205.) 

The  recto-abdominal  touch  (see  Chapter  V.,  page  53)  is  the 
one  to  be  employed  in  palpating  the  pelvic  organs  in  children. 
For  this  an  anesthetic  is  generally  necessary  in  the  case  of  very 
young  children,  but  in  older  children,  if  their  confidence  can  be 
gained,  ether  may  not  be  required.  The  utmost  gentleness  and 
delicacy  of  touch  must  be  employed  in  making  palpation  because 
of  the  relatively  small  size  of  the  sphincter  ani  and  the  friable 
nature  of  the  rectal  wall  in  infants  and  children.  The  sad  accident 
has  occurred  of  the  examining  finger  making  a  rent  through  the 


FIG.    203.  — The    Infantile 
Vulva.      (Williams.) 


ANOMALIES  557 

rectum  into  the  peritoneal  cavity  because  too  much  force  was  used. 
Because  of  the  relatively  greater  length  of  the  examining  finger 
and  the  small  size  of  the  pelvis  and  the  close  proximity  of  the 
abdominal  organs,  it  is  possible  in  little  children  to  palpate  the 
iliac,  hypogastric,  and  umbilical  regions  through  the  rectum,  and, 
in  addition  to  the  pelvic  organs,  in  this  manner  to  feel  a  diseased 
appendix  or  enlarged  mesenteric  glands.  Be  on  the  lookout  for 
a  full  bladder,  which  is  an  abdominal  organ  in  the  child,  and  may 
simulate  a  cystic  ovarian  tumor  or  a  collection  of  pus. 


The  development  of  the  external  genital  organs  is  described  in 
the  chapter  on  the  diseases  of  the  vulva  (Chapter  XXI.,  page  392) 
and  the  reader  is  advised  to  consult  this  description  and  Figs. 
158  to  162,  page  395,  also  Fig.  71  (from  Kollmann),  page  198,  show- 
ing the  development  of  the  ovaries,  tubes,  uterus,  and  vagina,  before 
taking  up  the  congenital  affections  seen  in  children.  Fig.  204, 
page  558,  after  Webster,  shows  the  anatomy  of  the  pelvic  organs 
in  the  new-born  child.  Note  that  the  vagina  is  relatively  long, 
the  cervix  is  long  compared  with  the  body  of  the  uterus,  and  the 
uterus  is  in  a  position  of  retroposition  with  anteflexion,  besides 
being  high  in  the  false  pelvis. 

The  congenital  anomalies  of  the  vulva,  vagina,  uterus,  tubes, 
ovaries, — also  of  the  bladder  and  rectum,  are  treated  at  length  in 
the  chapters  devoted  to  these  subjects.  In  the  present  chapter  we 
will  consider  only  those  defects  of  the  generative  organs  that  cause 
symptoms  during  childhood  and  with  which  the  practitioner  must 
be  familiar. 

Adherent  Prepuce. — Adhesion  of  the  prepuce  to  the  clitoris  with 
retained  smegma  is  a  not  uncommon  condition  in  female  infants 
and  children.  Some  authors  consider  that  the  prepuce  is  adherent 
normally.  W.  A.  Edwards  (supplement  to  Keating's  ''Cyclopedia 
of  Diseases  of  Children,"  p.  872)  noted  adhesions  of  the  labia 
minora  nine  times  in  his  private  records  of  the  births  of  two  hundred 
and  fifty  female  children.  He  says  further  that  he  has  been  accus- 
tomed to  see  several  cases  of  adherent  prepuce  in  children  every 
year.  It  is  doubtful  whether  adherent  prepuce  is  often  a  cause  of 


558 


INFANCY  AND  CHILDHOOD 


grave  nervous  disease1,  but  this  acts  sometimes  as  a  cause  of  local 
irritation  and  of  enuresis  in  children.  In  cases  of  wetting  of  the 
bed  the  genitals  should  be  inspected  carefully  to  rule  out  this 
abnormality.  The  irritation  caused  by  the  adhesion  of  the  prepuce 
is  thought  to  be  a  cause  of  masturbation, — at  any  rate  the 
prepuce  is  often  found  adherent  in  masturbators. 

Labial  Hernia. — An  inguinal  hernia  sometimes  passes  along  the 
round  ligament  and  appears  in  the  labium  majus.    This  condition 


FIG.  204. — Longitudinal  Median  Section  of  the  Pelvis  of  a  New-born  Child. 
(After  Webster.)  Showing  relatively  long  cprvix  and  vagina,  retroposition 
with  anteflexion,  straight  sacrum  and  cartilaginous  coccyx. 

is  seen  in  late  childhood  occasionally,  and  not  rarely  in  infants.  The 
hernia!  sac  may  contain  omentum,  intestine,  or  ovary  and  tube. 
Hernia  of  the  ovary,  sometimes  accompanied  by  its  tube,  has  been 
met  fairly  often  in  female  infants  under  eighteen  months  of  age,  it 
being  due  apparently  to  the  normal  position  of  the  ovaries  and 
tubes  in  infancy  close  to  the  internal  openings  of  the  inguinal 
canals  (see  Fig.  206),  to  a  patent  canal  of  Nuck,  or  a  shortened 
round  ligament.  The  protrusion  can  be  traced  to  the  external 
abdominal  ring  above,  and  is  limited  to  the  upper  portion  of  the 


ANOMALIES 


559 


labium.  If  it  contains  omcntum  it  is  irregular  to  the  feel  and  flat 
to  percussion,  and  if  intestine  it  is  smooth  and  has  a  tympanitic 
note.  The  sac  is  generally  reducible  by  taxis  if  the  patient  is  re- 
cumbent unless  it  contains  an  ovary,  when  it  is  firmer,  flat  on  per- 
cussion, tender,  and  can  not  be  returned  to  the  abdominal  cavity. 
Labial  hernia  is  to  be  distinguished  from  hydrocele  of  the  labium 
majus  and  tumor  of  the  labium. 
Hydrocele  of  the  Labium  Majus. — Should  the  peritoneal  invest- 


FIG.  205. — Examination  of  the  Infantile  Vagina  and  Cervix  with  a  Kelly  Blad- 
der Speculum.     (Kelly.) 

mont  of  the  round  ligament  extend  downward  nearly  to  the  end 
of  the  ligament  in  the  labium  instead  of  terminating  as  normally 
in  the  inguinal  canal,  this  sac  of  peritoneum  (the  canal  of  Nuck) 
may  become  filled  with  serum,  thus  forming  a  hydrocele.  In  this 
case  there  is  a  firm  ovoid  tumor  in  the  labium  with  its  smaller  end 
upward.  It  can  not  be  reduced,  it  is  flat  on  percussion,  and  its  up- 
per pole  is  generally  separated  by  an  appreciable  distance  from  the 
external  abdominal  ring.  If  the  hydrocele  is  of  large  size,  fluctua- 


560  INFANCY  AND  CHILDHOOD 

tlon  may  be  made  out.  The  condition  is  a  rare  one  and  is  dis- 
tinguished from  labial  hernia  in  not  being  reducible  and  in 
presenting  a  flat  percussion  and  fluctuation.  The  differentiation 
from  a  tumor  of  the  labium  may  be  impossible.  Tumors  are  apt  to 
be  in  the  lower  part  of  the  labia  and  they  are  of  even  rarer  oc- 
currence. 

Imperforate  Hymen. — Imperforate  hymen,  as  pointed  out  in 
Chapter  XXL,  page  396,  is  a  misnomer,  the  condition  being  gener- 
ally one  of  atresia  of  the  lower  part  of  the  vagina.  It  is  rare  and 
generally  causes  no  symptoms  until  menstruation  is  established. 
The  results  of  not  recognizing  it  until  puberty  are  so  deleterious 
to  the  patient  that  the  obstetrician  should  satisfy  himself  by  a 
careful  examination  of  the  genitals  of  every  new-born  girl,  not 
only  that  the  hymeneal  opening  is  not  closed,  but  that  it  is  of  suffi- 
cient size  to  afford  proper  drainage  to  the  vagina.  For,  if  it  is  not, 
infections  and  inflammations  are  more  likely  to  occur  in  later 
years.  This  point  can  be  determined  easily  by  passing  a  catheter 
into  the  vagina.  If  the  catheter  will  not  pass,  a  proper  opening 
into  the  vagina  should  be  established  by  operation. 

The  physician  will  do  well  to  bear  in  mind  that  atresia  of  the  vulva 
and  vagina  arises  in  many  cases  from  the  infectious  diseases  and 
is  not,  as  formerly  taught,  "congenital."  An  apparent  trifling 
infection  of  the  genitals  in  childhood,  accompanied  by  minor  symp- 
toms, may  result  in  closure  of  the  vaginal  opening  or  a  gluing 
together  of  the  nymphse.  Therefore,  the  physician  should  watch 
his  female  infants  and  girls  who  are  suffering  from  typhoid  fever, 
smallpox,  scarlatina,  and  diphtheria,  with  great  care,  having  this 
possibility  in  mind.  As  pointed  out  by  Nagcl  in  1896,  it  is  rare  to 
find  true  congenital  atresia  of  the  vagina  except  in  cases  where 
there  is  also  present  some  arrest  of  development  of  the  uterus  or 
ovaries. 

L.  Pincus  (Monatsschr.  fur  Geb.  und  Gyn.,  1903,  XVII.,  p.  751) 
has  maintained  that  a  majority  of  cases  of  primary  absence  of  the 
menses,  supposed  to  be  due  to  congenital  obstruction  of  the  vagina, 
are  really  caused  by  atresia  of  the  vagina  accompanying  or  follow- 
ing the  infectious  diseases,  and  he  has  reported  cases  which  bear 
out  his  contention.  According  to  him  and  contrary  to  common 
belief,  typhoid  fever  is  the  most  frequent  cause  of  atresia,  and 
H.  A.  Kelly  ("Medical  Gynecology,"  page  248)  has  collected  nine 


ANOMALIES  561 

cases  from  the  literature  in  which  typhoid  fever  was  the  cause  of 
vaginal  atresia.  Smallpox,  as  we  might  expect  from  the  nature 
of  the  disease,  comes  next  in  frequency,  and  cases  are  reported  of 
atresia  following  dysentery,  pneumonia,  erysipelas,  cholera,  scar- 
latina, and  diphtheria.  Attention  has  been  called  to  this  subject 
only  in  recent  years  so  that  the  number  of  reported  cases  is  not 
as  yet  large. 

To  overlook  atresia  in  a  child  is  an  easy  matter,  therefore  the 
importance  of  instituting  a  minute  inquiry  as  to  the  presence  of 
vulvar  irritation  or  discharge  in  a  female  child  suffering  from  an 
infectious  disease  is  apparent,  and  in  the  presence  of  atresia  in 
children  of  more  mature  years  the  mother  should  be  questioned 
as  to  whether  these  symptoms  had  existed  during  or  following 
infectious  disease  in  the  child  in  the  past. 

Imperf orate  Rectum  and  Anus. — Starr  ("American  Text-Book  of 
Diseases  of  Children")  has  estimated  that  malformation  of  the 
rectum  and  anus  occurs  about  once  in  ten  thousand  births  and  is 
more  common  in  girls  than  in  boys, — if  we  include  anus  vaginalis. 
As  has  been  pointed  out  elsewhere  (see  Chapter  XX VI.,  page  495) 
the  rectum  and  anus  are  developed  from  entirely  different  struc- 
tures of  the  blastoderm — the  former  from  the  hind-gut,  the  latter 
from  the  proctodeum — therefore  malformation  of  one  does  not 
necessarily  imply  abnormality  of  the  other,  and  observations  show 
that  where  the  rectum  is  malformed  or  displaced  the  anus  is  com- 
monly normal,  and  vice  versa. 

Imperf  orate  Rectum. — Imperf  orate  rectum  is  comparatively 
common,  the  rectum  ending  in  an  open  tube  on  a  level  with  the 
reflection  of  the  peritoneum  on  the  rectum,  due  presumably  to  the 
failure  of  the  hind-gut  to  send  out  a  bud  (the  post-allantoic  gut) 
to  meet  the  proctodeum.  The  imperforate  rectum  may  open  into 
the  vagina,  and  in  this  case,  unless  imperforate  hymen  is  present 
also,  there  is  an  escape  of  meconium  or  feces  by  the  vagina. 

Imperforate  Anus. — Imperforate  anus,  due  to  failure  of  develop- 
ment of  the  proctodeum,  is  a  not  uncommon  anomaly.  There 
may  be  no  trace  of  the  anus,  or  its  situation  may  be  marked  by  a 
slight  depression  or  by  a  wart-like  prominence. 

Imperforate  anus  inth  anal  canal  ending  in  the  vulva  is  common 
and  is  confounded  with  imperforate  rectum  having  a  vaginal  outlet. 
Incontinence  of  feces  is  generally  present  in  these  cases. 

30 


502 


INFANCY  AND  CHILDHOOD 


Anus  well  formed  and  the  anal  canal  ending  above  in  a  cul-de-sac 
is  not  uncommon.  In  this  anomaly  the  child  on  straining  causes 
tho  septum  dividing  the  rectum  from  the  anal  canal  to  protrude 
from  the  anus. 

The  obstetrician  should  examine  the  anus  of  every  new-born 
child  with  a  view  to  discovering  the  abnormalities  just  described. 
His  little  ringer  well  anointed  and  introduced  through  the  sphincter 
ani  will  go  a  long  way  toward  finding  an  anomaly  before  it  has 
caused  serious  symptoms.  A  thorough  examination  must  be 


FIG.  206.— Pelvic  Organs  of  a  Female  Infant  at  Birth.  (After  Bland- 
Sutton.)  Showing  elongated  ovaries  and  the  Fallopian  tubes  in  close  relation 
with  the  internal  abdominal  rings. 

instituted  in  case  a  baby  has  not  had  a  movement  of  the  bowels 
within  twenty-four  hours  after  birth  and  in  case  there  is  incontinence 
of  feces. 

Prolapse  of  the  Uterus. — Prolapse  of  the  uterus  in  a  new-born 
child  is  a  rare  condition.  Ballantyne  and  Thompson  (Amer.  Journ. 
Obstet.,  1897,  Vol.  II.,  p.  3">)  reported  eight  cases  from  the  literature 
and  their  own  experience.  The  anomaly  seems  to  be  associated 
with  lumbo-sacral  spina  bifida  and  rectal  prolapse, — often  with 
club-foot  and  sometimes  with  hydroceplialus,  so  that  it  may  be 


ANOMALIES  563 

regarded  as  one  of  those  congenital  malformations  that  occur  hi 
children  destined  to  have  a  short  life.  Two  cases  are  on  record  of 
prolapse  in  girls  of  thirteen,  due  hi  one  case  to  a  persistent  cough 
and  hi  the  other  to  carrying  heavy  burdens.  I  have  myself  seen  a 
case  of  prolapse  hi  a  stout  full-grown  virgin  due  to  a  chronic 
diarrhea  with  tenesmus. 

Erosion  of  the  Cervix. — Congenital  erosion  of  the  cervix  is  a  con- 
dition that  would  hardly  excite  the  attention  of  the  general  prac- 
titioner unless  it  were  accompanied  by  a  persistent  vaginal  discharge. 
In  such  an  event  it  may  be  recognized  by  speculum  examination 
of  the  vagina.  Leopold  first  called  attention  to  the  occurrence  of 
erosions  in  babies  and  children  hi  1872.  Fischel  (Archiv.  fur 
GynaekoL,  1880,  Bd.  XVI.,  S.  192)  found  cervical  erosions  which 
he  examined  microscopically  hi  four  fetuses  still-born  at  term, 
in  two  infants  a  few  days  old,  hi  an  infant  fourteen  days  old, 
and  in  three  infants  three,  four,  and  five  weeks  old,  respectively. 
As  a  rule,  the  external  os  in  these  cases  is  found  in  the  form  of  a 
narrow  transverse  opening  amounting  often  to  a  split  in  the  crown 
of  the  cervix.  The  opening  is  surrounded  by  a  reddened,  velvety 
area  from  three  to  four  millimeters  wide.  Sometimes  the  eroded 
area  extends  higher  up  on  the  lateral  surfaces  of  the  cervix  than 
on  the  anterior  and  posterior  aspects,  and  hi  other  cases  the  erosion 
is  limited  to  the  crown  of  the  cervix  where  the  cervix  comes  hi 
contact  with  the  posterior  wall  of  the  vagina.  These  observations 
of  Fischel  have  been  confirmed  by  later  observers,  notably,  in  our 
own  country,  by  C.  B.  Penrose.  He  says  ("Diseases  of  Women," 
sixth  edition,  p.  174): — "Erosion  of  this  character  has  been  found 
in  a  more  or  less  marked  degree  in  thirty-six  per  cent  of  new-born  in- 
fants." It  predisposes  to  erosion  in  the  adult  virgin  and  appears 
to  be  due  to  lack  of  proper  development  of  the  external  os,  so  that 
the  sharp  line  of  demarcation  between  the  squamous  epithelium  of 
the  vaginal  portion  of  the  cervix  and  the  cylindrical  epithelium  of 
the  mucosa  of  the  cervical  canal  is  not  formed,  and  the  cervical 
mucosa  appears  on  the  crown  of  the  cervix.  The  affection  has  no 
characteristic  symptoms.  In  the  girl  of  more  mature  years  congen- 
ital erosion  may  cause  a  mucoid  vaginal  discharge,  a  sense  of 
weight  in  the  pelvis  and  perhaps  backache.  In  this  event  the 
vagina  should  be  inspected  with  a  small  Sims  speculum,  or  a  large 
Kelly  cystoscope. 


564  INFANCY  AND  CHILDHOOD 

Precocious  Menstruation  and  Precocious  Maturity. — Genital  hem- 
orrhage in  the  new-born  does  not  constitute  precocious  menstrua- 
tion. A  flow  of  one  to  five  days'  duration  must  recur  at  regular 
intervals  and  be  attended  by  various  feelings  of  discomfort  anal- 
ogous to  those  experienced  by  women  at  the  catamenia,  in  order 
to  be  classed  as  premature  menstruation.  V.  Gautier  (Rev.  mcd. 
de  la  Suisse  romande,  1884,  IV.,  p.  501)  reported  twenty-four  cases 
of  this  affection  and  Dr.  John  Lovett  Morse  (Archives  of  Pediatrics, 
1897)  had  brought  the  number  of  reported  cases  up  to  thirty-five 
in  1897.  In  this  series  the  first  flow  began  all  the  way  from  one 
week  after  birth  to  the  seventh  year,  and  regular  menstruation 
persisted  from  three  months  to  five  and  a  half  years.  Numerous 
cases  have  been  reported  since.  Precocious  maturity  involves  a 
rapid  growth  of  the  whole  body  in  height  and  weight,  also  changes 
in  the  size  and  shape  of  the  genital  organs  and  mammary  glands, 
the  growth  of  hair  about  the  genitals  and  in  the  axillae,  and  regular 
menstruation.  In  older  children  who  are  instances  of  precocious 
maturity  there  is  generally  noted  by  the  parents  a  marked  pre- 
dilection of  the  child  for  the  opposite  sex. 

Menstruation  is  rarely  the  first  symptom  observed,  in  precocious 
maturity,  but  follows  the  changes  in  body  development  already 
noted.  Gautier  and  Morse  (loc.  cit.)  collected  together  fifty-seven 
cases  of  this  condition  and  the  literature  has  shown  many  instances 
since.  Here  is  a  case  reported  by  C.  Wischmann,  of  Norway  (ab- 
stract in  Zentralbl.  fur  Kinderlieilk.,  1904,  9,  p.  46).  The  child 
was  born  September  4,  1899,  and  a  discharge  of  blood  from  the 
genitals  was  first  noted  February  24,  1901.  In  the  succeeding 
sixteen  months  twelve  menstrual  periods  were  observed.  The 
child  was  large,  the  breasts  were  full,  and  the  mammary  glands 
well  developed.  There  was  hair  on  the  mons  veneris  and  in  the 
axillae.  There  were  no  evidences  of  rickets  and  there  was  no  his- 
tory of  similar  abnormalities  in  the  family. 

Dr.  Morse,  (loc.  cit.)  reported  a  case  which  I  saw  and  examined 
for  him  on  November  9,  1896,  when  the  child  was  fourteen  and  a 
half  months  old.  The  facts  in  the  case  were  briefly  these: — The 
child  was  born  August  29,  1895,  and  was  said  to  have  weighed 
fourteen  pounds  at  birth.  At  that  time  her  breasts  were  large  and 
the  baby  was  very  fat  in  the  neck.  There  was  no  history  of  early 
menstruation  in  the  family  except  that  the  mother  began  to  men- 


ANOMALIES 


565 


struate  at  twelve.  One  previous  child,  a  boy  three  years  old,  was 
normal  in  every  respect.  When  two  months  old  the  mother  noticed 
that  the  baby  had  the  "whites"  and  that  there  was  a  little  coarse 
hair  on  the  vulva.  On  May  29,  1896,  when  exactly  nine  months 
old,  a  bloody  vaginal  discharge  was  noted.  Weight  then  was 
twenty-eight  and  a  half  pounds, — breasts  large,  mons  veneris 
prominent,  and  external  genital  organs  well  developed.  A  flow 
of  three  days,  recurring  each  month,  occurred  regularly  until  she 
was  examined  November  9,  1896,  and  a  leucorrhea  was  noted 


FIG.   207. — A  Case  of  Precocious  Maturity. 

months  old. 


Child  fourteen  and  a  half 


during  the  intermenstrual  period.  There  were  no  evidences  of 
immodesty  or  sexual  feelings.  Then  her  appearance  was  that  of 
a  child  of  three, — weight  thirty-six  pounds,  height  thirty-two 
and  a  half  inches,  two  teeth,  intelligence  above  the  average,  and 
could  say  several  words  distinctly  and  walked  well, — a  moderate 
growth  of  hair  in  the  axilla?  and  on  the  back,  breasts  prominent 
and  each  contained  a  mass  of  gland  tissue  as  large  as  a  pigeon's 
egg,  nipples  well  developed  and  surrounded  by  a  dark  areola  and  a 
little  hair.  Local  examination  showed:  (I  quote  from  my  notes 
made  at  the  time)  ''the  labia  majora  well  developed  and  meeting 
in  the  median  line,  a  spare  growth  of  light  brown  coarse  hair  on  the 


566  INFANCY  AND  CHILDHOOD 

mons  vcncris  and  outer  surfaces  of  the  labia  majora,  labia  majora 
well  developed  and  of  moderate  size,  clitoris  normal,  hymen  with 
central  opening  dilatable,  easily  admitting  my  little  finger,  which 
is  nine-sixteenths  of  an  inch  in  diameter,  for  a  distance  of  one  and 
a  half  inches  in  the  vagina,  rugae  of  vagina  normal  and  cervix  well 
formed,  and  of  normal  density.  Vagina  as  large  as  that  of  a  girl  of 
six  years." 

DISEASES  OF  THE  VULVA  AND  VAGINA 

Vulvo-Vaginitis. — In  discussing  imperforate  hymen  and  atresia 
of  the  vagina,  vulvo- vaginal  inflammation — more  particularly 
the  kinds  of  inflammation  that  attend  the  infectious  diseases- 
has  been  referred  to  as  a  cause  of  atresia. 

Simple  Vulvo-Vaginitis. — Epstein  has  described  a  form  of  vulvo- 
vaginitis  that  is  present  in  fetal  life  and  continues  after  birth.  It 
is  characterized  by  an  abundant,  glairy  mucoid  and  muco-purulent 
vaginal  discharge,  and  by  redness  and  excoriation  of  the  genitals. 
In  the  secretion  are  found  much  epithelium,  leucocytes,  and  many 
forms  of  bacteria, — notably  the  streptococcus  and  frequently  the 
bacillus  coli  communis,  but  never  the  gonococcus.  By  the  bacte- 
riological examination  this  rare  affection  is  distinguished  from  the 
common  gonorrheal  vulvo-vaginitis.  Many  authors  have  described 
a  non-gonorrheal  vulvo-vaginitis  occurring  in  infants  and  children 
of  all  ages.  It  is  due  in  some  cases  to  masturbation.  In  these 
cases  the  discharge  is  more  apt  to  be  mucoid  or  muco-purulent 
than  purulent — unlike  the  gonorrheal  form — and  the  disease  is 
not  so  rebellious  to  treatment  as  in  the  case  of  gonococcus  infection. 
Mendes  de  Leon  (abstr.  in  Jahrb.  fur  Kinder Jieilk.,  1908,  Vol.  67, 
p.  253)  thinks  that  the  staphylococcus  plays  a  role  in  the  etiology  of 
a  simple  vulvo-vaginitis  in  children  and  that  this  form  of  inflamma- 
tion is  contagious,  as  in  the  case  of  the  gonococcus  form. 

Gonorrheal  Vulvo-Vaginitis. — Of  late  years,  since  the  discharge 
coming  from  the  genitals  of  children  who  are  affected  with  inflam- 
mation in  that  region  has  been  examined  microscopically,  the  fact 
has  become  painfully  apparent  that  a  majority  of  the  cases  of 
vulvitis  are  caused  by  the  gonococcus.  Of  course  the  gonorrheal 
form  is  met  more  often  in  dispensaries  and  in  hospital  clinics  than 
in  private  practice.  Epidemics  of  the  disease  have  occurred  where 


DISEASES  OF  THE  VULVA  AND  VAGINA  567 

all  cases  started  from  one  child,  such  as  that  in  the  Babies'  Hospital 
in  New  York  in  1902  reported  by  L.  Emmett  Holt  (New  York 
Medical  Journal,  1905,  Vol.  81,  p.  521).  Another  evidence  of 
indirect  and  accidental  infection  is  an  epidemic  which  occurred  in 
the  city  of  Posen,  Germany,  in  1890,  when  two  hundred  and 
thirty-six  school  girls  aged  from  six  to  fourteen  years,  were 
taken  ill  with  vulvo-vaginitis  in  from  eight  to  fourteen  days 
after  using  the  same  public  bath-house,  where,  on  account  of 
limited  accommodations,  the  children  were  required  to  bathe  in 
the  same  tub.  Sometimes  the  infection  is  intentional,  due  to  the 
superstition  prevalent  among  some  of  the  ignorant  classes,  that  a 
man  may  rid  himself  of  gonorrhea  by  giving  it  to  a  virgin. 

According  to  the  published  statistics  of  dispensary  services,  the 
disease  is  most  frequent  in  the  new-born  and  during  the  first  five 
years  of  life, — then  it  is  frequent  again  just  before  puberty.  There 
is  reason  to  believe  that  in  a  good  many  cases  the  infection  has 
been  transmitted  to  the  child  intentionally.  To  show  the  frequency 
of  vulvo-vaginitis  among  the  children  seen  in  out-patient  clinics, 
we  may  cite  those  of  the  Mount  Sinai  Hospital  in  New  York,  as 
given  by  Sara  Welt-Kakels  (New  York  Medical  Journal,  1904,  Vol. 
80,  p.  689).  During  the  ten  years  from  1893  to  1903  she  saw  190 
cases  of  vulvo-vaginitis,  forming  one  and  six-tenths  per  cent  of  all 
the  children  seen.  In  the  Women's  Venereal  Department  of  the 
Johns  Hopkins  Hospital  Dispensary,  139  cases  of  vulvo-vaginitis 
were  seen  among  1,366  patients,  or  ten  and  two-tenths  per  cent 
("  Medical  Gynecology,"  p.  365).  These,  of  course,  were  hi  venereal 
cases  only.  Most  authors  regard  the  frequency  of  vulvo-vaginitis 
among  sick  children  as  about  one  per  cent. 

The  disease  may  be  acquired  from  the  mother  during  birth,  and 
O.  Heubner  ("Lehrbuch  der  Kinderheilkunde,"  1906,  p.  502) 
has  observed  a  case  where  an  infant  infected  with  gonorrheal 
ophthalmia  subsequently  became  infected  in  the  vulva,  because  of 
the  carelessness  of  the  nurse,  and  had  a  vulvo-vaginitis  and  a  ure- 
thritis.  This  author  thinks  that  in  cases  of  vulvo-vaginitis  in  the 
child  investigation  will  show  that  in  many  instances  the  mother 
will  be  found  to  have  had  a  chronic  leucorrhea.  The  use  of  the 
same  towels,  linen,  and  sponges  by  several  members  of  a  family  may 
be  the  means  of  spreading  the  infection  and  of  course  the  soiled 
fingers  of  the  nurse  or  the  mother  are  accountable  in  many  cases. 


56S  INFANCY  AND  CHILDHOOD 

Symptoms  of  Vulvo-Vaginilis. — The  symptoms  of  vulvo-vaginitis 
may  excite  little  attention.  In  the  case  of  a  baby  it  may  cry  on 
passing  water  and  an  older  child  may  complain  of  smarting  on 
micturition.  There  may  be  itching  or  burning  at  the  vulva  so  that 
the  child  scratches.  In  a  few  cases  Bartholin's  glands  are  swollen, 
but  they  do  not  suppurate.  The  inguinal  glands  may  be  swollen, 
but  a  bubo  is  not  formed.  If  attention  is  called  to  the  disease  in  its 
initial  stage  the  body  temperature  will  be  found  to  be  elevated. 
Often  the  mother  brings  the  child  to  the  physician  because  its 
linen  is  stained  with  yellow  spots.  In  cases  of  long  standing  the 
child  becomes  pale  and  its  general  health  suffers.  The  disease 
most  often  gets  into  the  chronic  stage  before  it  is  discovered  and  it 
runs  a  chronic  course  of  weeks  and  months  and  is  extremely  re- 
bellious to  treatment.  One  author  has  reported  finding  gonococci 
in  the  discharges  after  the  disease  had  existed  for  four  years.  W. 
J.  Butler  and  J.  P.  Long  (Journ.  Amer.  Med.  Asso.,  Oct.  17,  1908, 
p.  1301)  state  that  in  their  experience  in  institutional  epidemics 
of  vulvo-vaginitis  in  children  during  ten  years,  the  disease  is 
quite  as  intractable  to  treatment  as  in  adult  women. 

Diagnosis  of  Vulvo-Vaginitis. — On  separating  the  labia  the 
entire  vulva  is  found  to  be  red.  It  is  wiped  with  a  pledget  of  ab- 
sorbent cotton  and  by  pressure  on  the  perineum  from  behind,  pus — 
generally  of  a  greenish  color — comes  from  the  vagina  and  the 
urethra.  The  physician  should  not  introduce  his  finger  into  the 
rectum  in  cases  of  suspected  infection  of  the  genitals  because  of 
the  very  great  danger  of  introducing  infective  matter  in  that  organ. 
Cover  glasses  are  prepared  from  the  pus  for  microscopic  examination 
as  described  on  page  61.  Usually  the  gonococci  are  easily  demon- 
strated in  the  cells  by  the  Gram  method.  The  disease  is  differ- 
entiated from  simple  vaginitis  by  the  bacteriological  examination. 
Very  rarely  injuries  of  the  vulva  are  found  and  only  then  are  we 
justified  in  diagnosing  rape.  The  inflammatory  symptoms  gen- 
erally last  from  four  to  six  weeks  and  the  discharge  changes  from 
profuse  purulent  to  scanty  and  mucoid  as  the  disease  progresses. 
The  most  frequent  complication  seems  to  be  arthritis.  Gonorrheal 
peritonitis  has  been  reported  as  a  sequel  of  gonorrhea!  vulvo- 
vaginitis  by  at  least  twelve  different  authors,  therefore  it  may 
be  regarded  as  a  serious  complication. 

Tuberculosis  of  the  Vulva. — Whether  tuberculosis  of  the  external 


DISEASES  OF  THE  VULVA  AND  VAGINA  569 

genitals  is  ever  primary  in  those  organs  seems  to  be  doubtful. 
Briining,  according  to  Langstein  (Pfaundler  and  Schlossmann, 
"Diseases  of  Children"),  collected  forty  cases  in  which  the  disease 
seemed  to  start  in  the  tubes,  and  then  affected  in  order, — the 
ovaries,  uterus,  vagina,  and  vulva.  He  is  of  the  opinion  that 
primary  tuberculosis  of  the  external  genitals  has  not  been  proven 
because  the  diagnosis  in  the  cases  reported  has  been  made  clini- 
cally, whereas  definite  pathological  proof  of  the  absence  of  tuber- 
culosis elsewhere  in  the  body  is  necessary  before  deciding  that  the 
disease  has  originated  in  the  vulva. 

We  are  safe  in  saying  that  primary  tuberculosis  of  the  genital 
organs  in  children  usually  originates  in  the  Fallopian  tubes  and 
from  this  situation  is  transmitted  to  the  other  organs  of  the  genital 
tract.  The  disease  is  commonly  secondary  to  tuberculosis  of  the 
lungs.  In  any  event  it  is  a  rare  affection.  Secondary  tuberculosis 
of  the  pelvic  organs  is  seldom  recognized  in  young  children,  the 
symptoms  being  masked  by  the  symptoms  of  the  primary  pul- 
monary lesion.  The  appearances  and  the  diagnosis  are  described 
in  Chapter  XXI.,  page  408. 

Diphtheritic  Vulvitis. — Diphtheria  of  the  vulva,  secondary  to 
pharyngeal  diphtheria,  is  an  occasional  disease  of  childhood.  Several 
cases  of  primary  diphtheria  of  the  vulva  have  been  reported.  Jacobi 
(Archives  of  Pediatrics,  Feb.,  1891)  reported  firm  occlusion  of  the 
vulva  and  vagina  as  a  result  of  diphtheritic  inflammation,  and 
Hydrup-Pederson,  according  to  W.  A.  Edwards,  reported  the  case 
of  a  girl  of  fifteen,  who  during  an  attack  of  diphtheria  passed  a 
complete  cast  of  the  vagina.  Later  the  child  developed  a  marked 
atresia  of  the  vagina  which  was  cured  by  operation.  Diphtheritic 
vulvitis  is  characterized  by  swelling,  dark  red  discoloration,  and 
the  formation  of  a  thick  gray  membrane  covering,  and  adherent 
to  the  tissues.  Constitutional  symptoms  of  fever  of  moderate 
degree,  anorexia,  and  pallor  with  loss  of  strength  are  present.  The 
membrane  separates  from  the  underlying  tissues  in  the  course  of  a 
few  days,  leaving  an  ulcerated  surface,  and  there  is  a  foul-smelling 
vaginal  discharge.  The  Klebs-Loeffler  bacillus  is  found  in  the 
discharges  or  in  smears  made  from  the  affected  parts. 

Gangrene  of  the  Vulva,  or  Noma  Vulvae. — Gangrene  of  the  vulva, 
a  disease  similar  to  cancrum  oris,  may  attack  the  vulva  (usually 
one  of  the  nymplia'),  in  the  case  of  dirty  and  underfed  children, 


570  INFANCY  AND  CHILDHOOD 

or  as  a  complication  or  sequela  of  measles,  scarlatina,  erysipelas, 
or  typhoid  fever.  The  disease  is  not  so  common  as  it  was  formerly, 
especially  in  hospitals,  because  of  the  improved  hygienic  surround- 
ings and  aseptic  treatment.  Noma  of  the  mouth  is  often  associated 
with  noma  of  the  vulva.  For  instance,  Gierke  reported  thirteen 
girls  in  his  hospital  service  in  Stettin,  with  noma  of  the  mouth, 
four  of  whom  also  had  noma  of  the  external  genitals.  Loeschner, 
in  the  babies'  hospital  in  Prague,  noted  two  cases  of  noma  of  the 
vulva  among  twenty  cases  of  noma  of  the  mouth.  The  disease 
begins  usually  as  a  livid  red,  indurated  swelling  of  one  labium, 
soon  breaking  down  into  dirty  gray  or  dull  red  ulcerations  and 
followed  by  a  greenish-black  layer  of  gangrene.  The  constitutional 
symptoms  are  severe  and  the  disease,  though  rare,  is  a  serious  one. 

Sarcoma  of  the  Vagina. — Sarcoma  of  the  vagina  is  by  no  means 
a  rare  affection  in  children.  Although  there  are  only  forty  or  so 
authentic  cases  reported  in  the  literature,  there  have  been  numerous 
cases  of  polyp  of  the  vagina  reported  without  microscopic  exami- 
nations of  the  tumor.  Now,  polyp  of  the  vagina  is  a  morbid  con- 
dition in  children  that  is  unknown  to  the  pathologist.  The  known 
new  growths  of  the  vagina  beskles  sarcoma  are, — cysts,  myoma, 
carcinoma,  venereal  warts,  and  the  extremely  rare  primary  chorio- 
epithelioma.  All  of  these  except  sarcoma  occur  almost  always  in 
adults,  and  this  occurs  in  both  adults  and  children.  Pedunculated 
primary  myoma  of  the  vagina  might  be  mistaken  for  sarcoma, 
but  of  the  seventy  cases  of  myoma  reported  only  one  or  two  oc- 
curred in  the  child.  Edwards  has  been  able  to  find  no  case  of 
primary  carcinoma  in  the  child,  but  he  cites  two  cases  of  primary 
chorioepithelioma  of  the  vagina,  in  children  thirteen  and  twelve 
years  old,  respectively.  I  think  these  should  be  viewed  with  sus- 
picion as  yet,  until  further  observations  have  been  made.  There- 
fore we  must  consider  the  cases  of  vaginal  polypi  so  frequently 
referred  to  in  the  literature  as  instances  of  sarcoma,  until  the  con- 
trary has  been  proven. 

Sarcoma  of  the  vagina  in  children  generally  develops  in  the  first 
year  of  life  and  is  fatal  within  a  year  or  two.  In  most  cases  it  ap- 
pears to  be  present  at  birth.  Demme-Granicher  (L.  Pick,  Archiv 
fur  (hjnaek.,  1894,  46,  218)  reported  the  case  of  an  infant  in  whom 
a  nodule  the  size  of  a  pea  was  found  in  the  vagina  at  the  time;  of 
birth.  This  showed  no  signs  of  active  growth  until  the  sixth  year, 


GENITAL  HEMORRHAGES  571 

when  it  increased  rapidly  and  the  child  died  in  the  seventh  year, 
of  fibrosarcoma  of  the  vagina.  Other  instances  go  to  show  that 
the  disease  may  be  latent  just  as  in  this  case,  so  that  should  a  tumor 
of  the  vagina  be  discovered,  the  practitioner  will  err  on  the  side  of 
safety  if  he  removes  it  and  submits  it  to  a  microscopic  examination. 

Sarcoma  of  the  vagina  is  characterized  by  the  development  of  a 
mass  of  vesicle-like  polypi  of  a  dark  red  (hemorrhagic)  and  pinkish- 
gray  (translucent)  color,  arranged  in  racemose  clusters.  The  first 
evidence  of  the  disease  is  what  appears  to  be  a  polyp  similar  to  a 
mucous  polyp  of  the  uterus.  This  generally  springs  from  the 
anterior  wall  of  the  vagina,  though  a  certain  proportion  (perhaps 
a  quarter  of  the  cases)  have  been  found  on  the  posterior  wall.  This 
primary  tumor,  when  it  grows,  proliferates  rapidly  in  the  form  of 
the  racemose  polypi  and  soon  fills  the  vagina.  The  base  of  the 
tumor  becomes  broader  and  infiltrates  the  vaginal  wall,  the  disease 
tending  to  invade  the  bladder  early, — probably  because  it  begins 
in  close  proximity  on  the  anterior  vaginal  wall, — then  the  cervix 
and  uterus, — next  the  parametrial  cellular  tissue  with  the  uterus 
(causing  hydronephrosis),  and  finally  the  peritoneum.  The  disease 
progresses  rather  slowly,  seldom  extends  to  the  rectum,  and  me- 
tastases  to  distant  organs  are ,  infrequent.  Therefore,  prompt 
recognition  and  removal  offer  a  good  chance  for  permanent  cure. 
Histologically  sarcoma  of  the  vagina  may  represent  all  the  different 
varieties  of  sarcoma. 

The  diagnosis  before  the  disease  has  progressed  extensively  is 
very  difficult.  A  vaginal  discharge  in  an  infant,  or  the  presence  of 
any  tumor  in  the  introitus  vagina?,  should  lead  at  once  to  an  ex- 
amination with  a  Kelly  cystoscope,  followed  by  the  prompt  removal 
of  adventitious  tissue  for  microscopic  examination. 


GENITAL  HEMORRHAGES 

As  previously  stated,  hemorrhage  from  the  vulva  does  not  con- 
stitute precocious  menstruation.  Hemorrhagic  disease  of  infants 
or  children,  or  iicmnphilia,  is  an  inherited  taint  characterized  by 
bleeding  on  slight  trauma  or  spontaneously  from  any  of  the  cavi- 
ties of  the  body  that  are  lined  with  mucous  membrane, — the  nose, 
the  mouth,  the  intestines,  the  stomach,  and  other  organs.  It  is 


572  INFANCY  AND  CHILDHOOD 

generally  not  manifest  before  the  second  year  and  an  attack  of 
bleeding  is  usually  accompanied  by  fever,  and  hemorrhage  takes 
place  from  several  situations.  In  purpura  also,  hemorrhage  may 
take  place  from  the  genitals  as  well  as  from  other  mucous  mem- 
branes. This  disease  is  apt  to  occur  in  cachectic,  rachitic,  or  anemic 
children  and  is  commonly  observed  between  the  second  and  the 
tenth  year.  Here  also  fever  is  present  and  the  bleeding  is  from 
several  sources.  These  diseases  have  nothing  to  do  with  the  dis- 
ease about  to  be  described. 

Hemorrhage  from  the  Vulva  in  the  New-born. — The  occurrence 
of  this  affection  in  infants  who  were  not  the  subjects  of  hemo- 
philia or  purpura,  was  observed  thirty-five  times  in  ten  thousand 
female  children  by  Schulkowski,  and  Cullingworth  saw  thirty-two 
cases  in  children  under  six  years  of  age.  J.  Zappert  (Wiener  med. 
Woch.,  1903,  No.  31)  had  observed  occasionally  a  bloody  mucoid 
discharge  from  the  vulva  in  new-born  girls  from  the  fifth  to  the 
sixth  day  after  birth.  There  were  no  attending  symptoms  such  as 
pain,  and  the  discharge  was  of  short  duration,  did  not  recur,  and 
seemed  to  be  entirely  harmless.  Zappert  was  enabled  to  examine 
a  portion  of  a  uterus  from  a  child  who  had  typical  hemorrhage  of 
this  kind.  The  genitals  appeared  to  be  normal  and  there  had  been 
no  previous  sepsis.  Microscopic  examination  of  the  portion  of  the 
uterus  showed  only  excessive  vascularity  of  the  submucous  tissue 
and  extravasation  of  blood  corpuscles  from  the  dilated  vessels, 
but  an  intact  epithelium  of  the  mucous  membrane  and  an  absence 
of  all  traces  of  inflammation, — an  analogous  condition,  in  other 
words,  to  the  histological  picture  of  the  endometrium  of  the  men- 
struating uterus  in  the  adult.  Like  the  swelling  of  the  mammary 
glands  often  noticed  in  the  new-born,  this  hemorrhage  may  be  due 
to  some  physiological  stimulation  of  the  uterine  mucous  membrane. 

In  Schulkowski's  observations  the  hemorrhage  did  not  appear 
until  the  fifth  or  sixth  day  after  birth  and  he  considers  that  the 
cause  of  the  hemorrhage  is  a  physiological  hyperemia  of  all  the 
abdominal  organs  that  is  present  soon  after  birth. 

Hemorrhage  from  the  Vulva  in  Little  Girls.— J.  Comby  ("Traite 
dcs  Maladies  de  L'Enfance,"  1897,  p.  554)  insisted  that  a  local 
cause  was  to  be  sought  for  vulvar  hemorrhage's  in  little  girls,  and 
this  view  is  in  accord  with  the  facts  as  to  the  post-climacteric 
hemorrhages.  Although  in  the  latter  case  investigation  of  the 


GENITAL  HEMORRHAGES  ,          573 

genitals  is  usually  attended  by  less  difficulty,  we  should  not  be 
deterred  from  instituting  a  thorough  examination  in  infants  in 
case  the  bleeding  is  persistent,  or  recurs.  Comby  has  noted  hem- 
orrhage from  the  vulva  in  children  who  are  the  subjects  of  vulvo- 
vaginitis  and  he  cites  A.  Broca,  Pourtier,  Henoch,  Heinricius,  and 
Graefe,  each  as  having  found  prolapse  of  the  urethral  mucous 
membrane  a  cause  of  genital  hemorrhage  in  the  new-born.  The 
frequency  of  genital  hemorrhage  in  the  course  of  infectious  dis- 
eases may  well  be  due  to  inflammation  in  the  vagina  or  uterus  in 
these  cases.  Henoch  noted  hemorrhage  in  the  case  of  "papilloma 
of  the  vulva  or  vagina."  By  this  we  should  understand  now, 
sarcoma  of  vagina  or  vulva,  or  possibly  angioma,  which  has  been 
reported  by  Sanger  and  others.  Angiomatous  tumors  are  said  to 
degenerate  rapidly  and,  in  this  event,  might  well  cause  bleeding. 

Although  a  case  of  lipoma  of  the  vulva  in  a  five-months-old 
child  (Quinn,  Bull.  Soc.  de  chir.,  1890,  Vol.  16,  No.  1)  has  been 
reported,  it  seems  improbable  that  such  a  tumor  could  be  the 
cause  of  hemorrhage.  Carcinoma  of  the  vulva  and  vagina  is  un- 
known in  new-born  infants,  although  a  few  cases  are  on  record  of 
the  disease  in  older  children. 

Congenital  erosion  of  the  cervix,  prolapse  of  the  urethra,  vulvo- 
vaginitis  and  its  sequelae,  also  sarcoma  of  the  vagina  and  prolapse 
of  the  mucous  membrane  of  the  urethra,  should  be  kept  in  mind 
by  the  physician  as  possible  causes  of  a  bloody  vaginal  discharge. 

Metrorrhagia  of  Puberty. — The  hemorrhages  from  the  genitals 
that  occur  at  the  time  of  puberty  may  be  of  varied  causation 
according  to  P.  Hours  (These  de  Paris,  1908)  who  reported  fifteen 
cases.  He  enumerates  the  following  as  causes: — Fungous  endo- 
metritis  following  infection  from  the  vagina,  uterine  new  growths, 
diseases  of  the  heart,  liver,  or  kidneys,  chlorosis,  hemophilia, 
purpura,  the  eruptive  fevers,  and  finally  and  most  frequent,  the 
general  infections  and  toxemias.  The  possibility  that  the  nervous 
system,  governor  of  the  menstrual  function,  may  not  become  adjusted 
at  once  and  that  hemorrhage  as  well  as  scanty  menstruation  may 
occur  in  girls  at  puberty  without  discoverable  lesion  of  the  genitals, 
should  bo  in  the  physician's  mind.  But,  on  the  other  hand,  he 
should  not  sit  with  hands  folded  and  let  "Nature"  work  out  the 
problem  unassisted.  The  rational  procedure  in  all  cases  of  vaginal 
hemorrhage  is  to  make  a  local  examination  and  try  to  find  the 


T>74  INFANCY  AND  CHILDHOOD 

cause  at  first  hand.  Even  if  no  local  cause  is -found,  the  physician 
will  treat  his  patient  more  understandingly  with  the  knowledge 
that  she  has  no  manifest  lesion  of  the  genitals. 


MASTURBATION 

Masturbation  (from  the  Latin,  masturbare,  to  pollute  one's  self) 
is  a  much  commoner  condition  in  children  than  is  generally  thought 
by  the  profession.  We  must  distinguish  two  sorts, — (1)  that 
occurring  in  infants,  called  by  B.  K.  Rachford  "  Pseudomasturba- 
tion,"  (Archives  of  Pediatrics,  Aug.,  1907,  p.  561)  and  (2)  true 
masturbation,  occurring  in  older  children. 

(1)  Pseudomasturbation. — This  has  been  described  under  the 
titles, — "Thigh  Friction,"  and  "Infantile  Masturbation."  It  is 
accomplished  generally  by  the  child  lying  on  its  back,  the  thighs 
are  flexed,  crossed,  and  pressed  tightly  together,  closely  embracing 
the  genitals.  In  this  position  the  infant  rubs  its  thighs  together 
or  makes  up  and  down  movements  with  its  body.  Sometimes 
it  rubs  itself  against  its  mother,  or  the  corner  of  the  crib,  or  other 
foreign  objects,  seldom  using  its  hands.  The  movements  are 
evidently  attended  by  pleasurable  sensations,  with  nervous  tension, 
excitement,  flushing  of  the  face,  staring  eyes  and  large  immobile 
pupils,  followed  in  a  few  minutes  by  perspiration,  relaxation,  con- 
tentment or  exhaustion,  and  sometimes  by  sleep.  This  sort  of 
masturbation  occurs  as  early  as  the  fourth  month  and  the  average 
age  was  sixteen  months  in  the  table  of  fifty-two  cases  reported  by 
Rachford.  He  explains  its  early  occurrence  by  the  fact  that  the  ex- 
ternal genital  organs  in  the  girl  are  practically  fully  developed  and 
endowed  with  physiological  function  at  birth,  whereas  the  internal 
organs  of  generation  do  not  attain  their  full  growth  until  the  child 
is  ten  years  old.  Partly  on  this  account  and  partly  because  the 
infant  can  have  no  sexual  thoughts,  he  thinks  this  sort  of  mastur- 
bation should  be  distinguished  from  the  masturbation  of  older 
children  and  adults.  Of  the  fifty-two  cases  collected  by  this  author 
by  eighteen  different  reporters,  forty-eight  were  in  female  infants,— 
therefore  the  affection  may  be  said  to  belong  to  the  female  sex. 
This  can  be  explained  on  the  ground  of  the  proximity  of  the  openings 
of  the  urinary  and  fecal  canals  to  the  sensitive  vulva,  and  to  the 


MASTURBATION  575 

fact  that  the  clitoris,  being  less  protected  by  the  labia  than  in  the 
adult,  is  more  exposed  to  excitation  and  irritation  by  necessary 
handling  in  the  interests  of  cleanliness.  A  hyperacidity  of  the 
urine  existed  in  more  than  half  of  the  reported  cases.  Therefore, 
this  must  be  considered  as  a  cause.  Intestinal  worms,  proctitis, 
adherent  prepuce,  and  uncleanliness  must  be  reckoned  as  causative 
also.  Heredity  in  the  form  of  a  neurotic  inheritance,  meaning  an 
unstable  nervous  system  in  a  poorly  developed  body,  existed  in 
three-fourths  of  the  cases  and  L.  Emmett  Holt,  in  forty-six  cases 
in  his  private  records,  was  struck  with  the  great  frequency  of 
masturbation  in  mentally  defective  children. 

(2)  Masturbation  in  Older  Children. — In  older  children  the 
practice  of  masturbation  is  more  commonly  found  in  boys  than 
in  girls.  The  example  of  other  children  is  an  important  factor  in 
establishing  the  practice,  and  when  the  habit  is  once  formed  it  is 
hard  to  break. 

As  regards  its  effect  on  the  child  most  authorities  are  agreed  that 
it  is  deleterious,  but  not  very  serious  in  most  cases  unless  practiced 
to  excess.  The  vice  is  thought  to  be  present  in  the  nervously  or 
mentally  defective,  and  to  accompany  such  conditions  as  a  result 
and  not  as  a  cause.  0.  Heubner  has  noticed  derangement  of  the 
heart  in  masturbating  children,  especially  idiopathic  hypertrophy 
with  dilatation, — particularly  of  the  left  ventricle, — and  irregularity 
of  action  during  violent  exercise.  Masturbating  children  with 
strong  bodies  show  fewer  symptoms  than  those  with  weak  bodies. 
Edwards  (loc.  cit.)  says  that  masturbating  children  often  do  serious 
damage  to  the  sexual  organs,  citing  Bokai's  case  in  which  a  girl  of 
ten,  who  for  a  long  time  had  practiced  masturbation,  for  the  same 
purpose  had  ligated  the  clitoris  so  tightly  with  a  thread  that  the 
organ  swelled  up  to  the  size  of  an  Italian  hazel-nut.  The  thread 
was  removed  fourteen  days  later  and  it  became  necessary  sub- 
sequently to  remove  the  hypertrophied  clitoris  with  the  thermo- 
cautery. 

Sometimes  children  introduce  foreign  bodies  into  the  vagina 
for  purposes  of  masturbation,  but  this  practice  is  not  so  common 
as  in  the  case  of  adults.  J.  P.  West,  who  has  reported  several  cases, 
says :  "  A  number  of  children  who  do  not  thrive  after  every  care  and 
attention  has  been  given  for  every  disease  or  trouble  that  could 
be  found,  will  -prove'  to  be  masturbators.  I  have  seen  many 


576  INFANCY  AND  CHILDHOOD 

illustrations  of  this  and  have  been  deceived  not  a  few  times  by 
parents  who  were  unwilling  to  acknowledge  the  practice  of  this 
habit  in  their  child." 

If  a  child  is  addicted  to  this  vice  the  diagnosis  is  established 
only  by  observing  the  practice.  Abnormalities  of  the  genital 
organs  and  of  the  urine  should  be  excluded  by  a  local  examination 
and  by  urinalysis  before  measures  of  treatment  are  instituted. 


MALIGNANT  DISEASE  OF  THE  UTERUS 

Recent  investigation  of  the  literature  by  W.  A.  Edwards  (Amer. 
Journ.  Med.  Sci.,  July,  1909)  shows  twenty-three  reported  cases  of 
malignant  disease  of  the  uterus  in  children  between  nine  months 
and  fifteen  years  of  age.  Sixteen  of  these  were  primary  sarcoma 
and  seven  carcinoma,  three  of  the  latter  being  cancer  of  the  cervix. 
There  were  many  varieties  of  sarcoma  reported  and  the  cases  of 
sarcoma  of  both  uterus  and  vagina  where  the  point  of  origin  of  the 
disease  was  in  doubt  have  been  excluded  in  my  summing  up, — 
so  also  have  been  culled  out  a  case  of  cancer  of  the  abdominal  or- 
gans and  an  cncephaloid  cancer  in  a  young  woman  of  eighteen. 
Therefore  in  the  future  it  behooves  us  to  be  on  the  lookout  for 
malignant  disease  even  in  the  very  young. 

DISEASES  OF  THE  OVARIES  AND  TUBES 

Ovarian  tumors  are  fairly  common  in  children,  especially  the 
cmbryomata  and  cystadenomata.  Bland-Sutton  over  ten  years 
ago  had  collected  one  hundred  cases  of  ovariotomy  performed  on 
children  under  sixteen  years  of  age  and  Olshausen  among  one 
thousand  seven  hundred  and  sixteen  ovariotomies  has  operated 
on  children  sixty-one  times.  Ovarian  tumors,  although  found  in 
infancy,  become  more  frequent  as  puberty  is  approached.  W. 
A.  Edwards  (loc.  cit.)  has  recently  collected  forty-eight  cases  of 
malignant  disease  of  the  ovary  in  children  fifteen  years  old  or 
younger,  the  youngest  being  a  fetus  seven  months  old.  Sarcoma 
of  various  sorts,  or  carcinoma  was  found  in  every  case,  sarcoma 
being  the  more  frequent.  There  are  many  cases  in  the  recent 
literature  of  primary  tuberculosis  of  the  tubes  in  children,  and 


DISEASES  OF  THE  OVARIES  AND  TUBES  577 

also  of  gonorrheal  salpingitis  from  extension  upward  of  the  infec- 
tion of  vulvo-vaginitis.  Some  of  these  last  cases  are  attended  by 
general  peritonitis  of  a  severe  type. 

After  the  infectious  diseases,  as  pointed  out  by  Lebedinski, 
Skobansky,  and  others,  there  is  a  degeneration  of  the  Graafian 
follicles  of  the  ovaries  just  as  there  is  degeneration  hi  the  other 
parenchymatous  organs  after  these  diseases.  Therefore,  the 
function  of  the  ovaries  is,  for  a  time  at  least,  more  or  less  impaired 
by  scarlet  fever,  typhoid  fever,  and  diphtheria.  Massin  (Archiv 
fiir  Geb.  and  Gyn.,  1891,  XL.,  p.  146)  showed  that  the  uterus 
exhibited  endometritis  after  typhoid  fever,  pneumonia,  dysentery, 
and  "  relapsing  fever  " ;  but  Jung  (Zentralb.  fiir  Gyn. ,  1904,  XXVIII. , 
p.  991),  after  an  exhaustive  investigation  of  gonococcus  infection, 
thinks  that  the  gonococcus  from  vulvo-vaginitis  seldom  lurks  in 
the  cervical  canal  in  children. 

Symptoms  and  Diagnosis. — On  account  of  the  small  size  of  the 
child's  pelvis  there  is  an  early  ascent  of  an  ovarian  tumor  into  the 
abdomen ;  in  fact,  the  ovaries  are  abdominal  organs  hi  the  infant. 
Therefore,  pressure  on  the  bladder  and  rectum  is  rarely  present  hi 
the  case  of  ovarian  tumors  hi  the  child.  On  the  other  hand,  a 
relatively  small  tumor,  owing  to  the  limited  room  for  expansion, 
causes  marked  disturbances  of  digestion  and  respiration.  The  child 
is  easily  fatigued  and,  if  old  enough  to  call  attention  to  her  dis- 
comforts, may  complain  of  pain  in  the  abdomen.  The  watchful 
mother  notices  an  undue  prominence  of  the  abdomen  and  that 
the  child's  appetite  is  impaired  and  her  breathing  short. 

The  diagnosis  of  diseases  of  the  ovaries  and  tubes  in  children  is 
made  by  the  bimanual  recto-abdominal  touch.  It  is  well  to  first 
put  the  child  in  the  knee-chest  position  and  admit  air  into  the 
rectum  by  passing  a  cystoscope  or  catheter  through  the  anus. 
Great  gentleness  should  be  used  in  making  the  bimanual  touch. 
Owing  to  the  small  size  of  the  pelvis  and  the  straightness  of  the 
sacrum  in  the  child,  a  comparatively  small  tumor  of  the  ovary 
may  appear  to  be  high  in  the  abdomen  and  springing  from  the 
liver  or  kidney  because  of  the  small  amount  of  space  in  the  child's 
abdomen.  An  anesthetic  should  be  used  for  the  examination, 
perhaps  only  a  few  whiffs  of  ether  or  chloroform  being  given. 
Find  first  the  position  of  the  long  cervix  and  short  uterine  body. 
In  comparison  to  the  body  the  cervix  appears  at  first  to  be  unduly 
37 


578  INFANCY  AND  CHILDHOOD 

largo.  It  is  high  in  the  pelvis.  (Sec  Figs.  204  and  206.)  The 
ovaries  arc  like  little  cucumbers  with  their  long  axes  corresponding 
with  the  long  axis  of  the  Fallopian  tubes  and  they  are  close  to  the 
pulsating  external  iliac  arteries;  also,  the  uterus  being  so  high,  the 
utero-sacral  ligaments  are  arched  in  the  shape  of  a  bow  and  may 
be  felt  as  guides  to  the  ovaries.  In  the  case  of  an  ovarian  tumor 
one  ovary  of  course  will  be  wanting.  The  cervix  may  be  drawn 
down  with  a  double  tenaculum  held  by  an  assistant  while  the  bi- 
manual  touch  finds  and  determines  the  length,  breadth,  and  thick- 
ness of  the  pedicle  of  a  tumor,  just  as  in  the  adult.  (See  Fig.  126, 
page  301.) 

A  discussion  of  the  different  sorts  of  tumors  both  of  the  ovaries 
and  of  the  Fallopian  tubes  will  be  found  in  the  chapters  devoted  to 
these  subjects.  Suffice  it  to  say  here  that  sarcoma  of  the  ovary  and 
tuberculosis  of  the  tubes  are  rather  more  frequent  in  children  than 
many  of  the  other  affections. 

DISEASES  OF  THE  BLADDER 

Practically  all  the  diseases  of  the  bladder  found  in  the  adult  are 
met  with  in  children.  The  anomalies  will  be  found  in  Chapters 
XXIII.,  XXIV.,  and  XXV.,  pages  444, 457,  486.  Here  we  will  refer 
to  some  of  the  commoner  affections.  Prolapse  of  the  mucous 
membrane  of  the  urethra  has  been  referred  to  in  the  section  on 
genital  hemorrhages. 

To  collect  the  urine  of  a  female  infant  place  a  small  cup  over  the 
vulva  and  hold  it  in  place  with  the  napkin.  If  the  infant  is  placed 
upon  a  chamber  regularly  every  ten  or  twenty  minutes  for  a  few 
hours  and  a  cold  compress  is  placed  over  the  bladder,  urine  may 
generally  be  obtained.  Cathoterization  with  a  soft-rubber  catheter 
under  aseptic  conditions  is  a  certain  and  reliable  means  of  getting 
a  specimen  of  urine. 

The  twenty-four-hour  amount  of  urine  in  infants  is  relatively 
greater  than  in  older  children  and  adults.  The  urine  is  passed  as 
often  as  twice  an  hour  during  the  waking  hours  of  the  first  two 
years  of  life,  while  during  sleep  it  is  retained  from  two  to  six  hours. 

Enuresis. — The  involuntary  voiding  of  urine,  especially  at  night, 
is  a  fairly  common  affection.  The  consideration  of  this  subject 
belongs  to  the  domain  of  neurology  rather  than  gynecology,  as 


DISEASES  OF  THE  BLADDER  579 

the  affection  is  due  in  a  majority  of  cases  to  derangement  of  the 
nervous  system.  (See  Chapter  X.,  p.  154.)  The  involuntary  dis- 
charge of  urine  is  normal  in  the  young  infant  and  it  becomes 
voluntary  only  at  a  later  age  and  is  dependent  largely  on  the 
child's  training.  In  most  children  the  urine  is  controlled  during 
the  waking  hours  after  the  first  year,  but  while  asleep  it  may  be 
passed  in  the  bed  as  late  as  the  second  year,  or  even  the  third  year, 
so  that  the  loss  of  control  during  sleep  should  not  be  regarded  as 
abnormal  until  the  end  of  the  third  year. 

During  five  years  at  the  Children's  Dispensary  of  the  University 
Hospital  in  Philadelphia,  Ostheimer  and  Levi  (Journ.  Amer.  Med. 
Asso.,  Dec.  17,  1904)  found  eighty-five  cases  of  enuresis  among 
one  thousand,  six  hundred  and  fifty-seven  new  patients,  or  about 
five  per  cent.  Townsend  had  one  case  of  rectal  polyp  in  a  girl 
suffering  with  incontinence  in  which  a  cure  was  effected  by  re- 
moving the  polyp.  Ostheimer  and  Levi  had  a  similar  case  in  which 
cure  was  not  obtained  by  removing  the  polyp.  Kerley  (Bost.  Med. 
and  Surg.  Journ.,  Vol.  CLV.,  pp.  172-174)  noted  the  presence  of 
urine  of  a  high  specific  gravity  and  hyperacidity  in  the  subjects  of 
incontinence  and  assigned,  as  causative  in  some  cases,  contracted 
bladder,  adhesions  of  the  prepuce,  vaginitis,  and  thread  worms. 
Suffice  it  to  say  here  that  in  case  of  enuresis  the  genital  organs 
should  be  carefully  examined  to  rule  out  abnormalities. 

Bacteriuria. — For  the  substance  of  this  section  I  am  indebted 
largely  to  Dr.  John  Lovett  Morse's  excellent  article,  "INFECTION 
OF  THE  URINE  AND  THE  URINARY  TRACT  BY  BACILLUS  COLI  IN 
INFANCY"  (Amer.  Journ.  Med.  Sciences,  Sept.,  1909). 

Bacteriuria  is  a  disease  characterized  by  the  presence  of  bacteria 
in  exceedingly  large  numbers  in  the  freshly  passed  urine,  and  by 
the  absence  of  marked  symptoms  of  an  inflammatory  process  in 
the  mucous  membrane  of  the  urinary  tract.  It  must  be  remembered 
that  the  presence  of  bacteria  in  the  urine  in  the  course  of  an  in- 
fectious nephritis,  or  in  a  general  infectious  disease,  does  not  con- 
stitute bacteriuria.  Bacteriuria  is  most  common  hi  infancy  and 
is  almost  always  due  to  the  bacillus  coli  communis.  Dr.  Morse  has 
seen  fifty  cases,  over  sixty  per  cent  of  them  being  in  girls.  Escherich, 
who  in  1894  first  pointed  out  the  frequency  of  bladder  affections 
in  girls,  observed  that  the  bacillus  coli  was  present  fifty-eight 
times  among  his  sixtv  cases. 


5SO  INFANCY  AND  CHILDHOOD 

There  are,  as  a  rule,  no  severe  general  symptoms  in  bacteriuria. 
There  may  be  slight  elevation  of  temperature  and  malaise.  Fre- 
queirt  and  painful  micturition  are  not  uncommon,  and  older  children 
who  are  the  subjects  of  this  disease,  often  suffer  from  incontinence. 
The  urine;  is  uniformly  cloudy,  having  the  appearance  of  a  bouillon 
culture  of  bacteria.  The  odor  is  foul  and  the  reaction  acid. 

Etiology. — Theoretically,  infection  of  the  urine  and  the  urinary 
tract  may  occur  in  three  ways:  (1)  Through  the  blood  (the 
hematogenous,  or  descending  theory);  (2)  Through  the  urethra, 
(the  ascending  theory),  and  (3)  Through  the  tissues  between  the 
intestines,  the  home  of  the  bacillus  coli,  and  the  bladder  (the 
transparietal  theory).  Without  going  into  a  detailed  analysis  of 
these  theories  it  is  sufficient  to  note  that  they  indicate  that  the 
route  of  infection  is  not  always  the  same.  It  seems  reasonable  to 
conclude,  however,  that  in  the  majority  of  the  cases  in  girls  the 
infection  is  through  the  urethra,  in  a  fair  proportion  it  is  trans- 
parietal,  while  it  is  occasionally  hematogenous.  Infection  of  the 
bladder  is  impossible  while  the  mucosa  is  normal;  therefore  some 
lesion  or  abnormality  of  this  membrane  is  a  contributory  cause. 

Pathology. — Reddening  or  swelling  of  the  mucous  membrane  of  a 
whole  or  a  part  of  the  urinary  tract  with  some  desquamation  of 
the  epithelium,  and,  in  some  cases,  evidences  of  degeneration  of 
the  lower  tubules  of  the  kidney,  are  the  only  pathological  changes 
that  have  been  observed  in  bacteriuria.  The  disease  may  be  second- 
ary to  disturbance  of  the  intestinal  tract;  often  the  determination 
as  to  whether  the  internal  disturbance  is  before,  or  after  the  bac- 
teriuria, is  a  difficult  matter  to  settle. 

Symptoms  and  Diagnosis. — In  a  majority  of  cases  the  symptoms 
are:  elevation  of  temperature,  restlessness,  drowsiness,  frctfulness, 
and  signs  of  discomfort.  Anorexia  is  the  rule,  and  disorder  of 
function  of  the  gastro-intestinal  tract  is  especially  common.  Vomit- 
ing is  not  unusual  and  the  movements  of  the  bowels  are  abnormal. 
Frequent  and  painful  micturition  may  be  present  if  there  is  a  cys- 
titis or  urethritis,  or  tenderness  in  the  kidney  region  if  the  kidney 
is  involved.  Often  the  staining  of  the  baby's  napkins  yellow,  by 
the  turbid  urine,  first  calls  attention  to  the  condition. 

Examination  of  (he  urine  shows  the  urine  to  be  pale  and  uniformly 
cloudy,  the  cloudiness  being  due  in  part  to  the  bacteriuria  and  in 
part  to  the  presence  in  the  urine  of  large  numbers  of  pus  cells. 


DISEASES  OF  THE  .BLADDER  581 

Sometimes  the  urine  has  a  gelatinous  appearance.  The  odor  may 
be  normal,  but  it  is  generally  foul.  The  specific  gravity  is  not 
abnormal  and  the  twenty-four-hour  amount  varies  only  with  the 
amount  of  liquids  ingested.  The  reaction  is  almost  invariably 
acid  and  not  infrequently  strongly  acid.  The  Bacillus  coli  does 
not  decompose  urea  and  thrives  in  an  acid  medium,  though  pre- 
ferring an  alkaline  or  neutral  medium.  The  acidity  of  the  urine 
being  hostile  to  the  growth  of  other  bacteria,  the  Bacillus  coli  is 
usually  found  in  pure  culture.  The  urine  usually  contains  less 
than  one  tenth  of  one  per  cent  of  albumin  and  under  the  micro- 
scope the  sediment  is  seen  to  be  composed  largely  of  pus  cells, — 
usually  single,  sometimes  in  clumps.  Caudate,  small  round  cells, 
and  squamous  cells  in  small  numbers  are  present  hi  many  cases, 
but  squamous  cells  are  never  to  be  found  in  large  numbers,  as  they 
are  in  purulent  inflammation, — probably  because  of  the  absence  of 
the  ammoniacal  products  of  the  decomposition  of  urea,  which  are 
the  cause  of  the  destruction  and  desquamation  of  bladder  epithe- 
lium in  inflammatory  affections  of  the  bladder.  Hyaline,  or  fine 
granular  casts  are  seen  occasionally, — blood  almost  never.  The 
disease  has  been  confused  with  typhoid  fever  and  with  malaria 

Cystitis  and  Stone  in  the  Bladder. — Cystitis,  a  true  inflammation 
of  the  bladder,  is  now  known  to  be  of  relatively  frequent  occurrence 
in  female  infants  and  little  girls,  though  extremely  rare  in  male 
infants.  It  is  most  often  observed  in  the  first  three  years  of  life. 
Stone  in  the  bladder,  on  the  other  hand,  occurs  twenty  times  in 
the  male  to  once  in  the  female  child.  This  is  due,  probably,  to  the 
short  urethra  in  the  female,  offering  not  only  opportunity  for 
infection  from  without,  but  an  easy  escape  for  calculi  from  the 
bladder.  Since  Escherich  called  the  attention  of  the  profession  to 
the  frequency  of  cystitis  in  1894,  cases  have  been  reported  in  the 
literature  with  ever-increasing  frequency;  probably  many  of  these 
being  cases  of  bacteriuria,  however. 

The  three  theories  as  to  the  route  of  the  infective  bacteria  in 
their  course  to  the  bladder,  ascending,  descending  or  hematogenous, 
and  transparietal,  have  been  referred  to  in  the  discussion  of  bac- 
teriuria. Cystitis  is  due  in  a  majority  of  cases,  just  as  with  the 
last  disease,  to  (a]  the  bacillus  coli  communis  which  reaches  the 
bladder  by  any  of  the  three  ways,  but  generally  through  the  urethra. 
It  may  be  due  to  (/>)  the  tubercle  bacillus,  and  in  this  event  the 


582  INFANCY  AND  CHILDHOOD 

process  is  almost  always  a  descending  one,  the  disease  originating 
in  the  kidneys,  or  it  is  transmitted  through  the  blood  from  the  lungs 
or  other  focus,  (c)  Gonococcus  infection  of  the  bladder  is  a  process 
ascending  through  the  urethra;  so  is  (d)  a  diphtheritic  cystitis  fol- 
lowing diphtheria  of  the  vulva.  The  infections  from  (e)  staphylo- 
coccus,  or  (f)  streptococcus  are  generally  secondary  to  suppuration 
in  the  kidney,  but  may  come  by  either  of  the  other  two  routes. 

Cystitis  is  present  in  some  degree  in  practically  every  case  of 
stone  in  the  bladder,  because  the  calculus  inflicts  trauma  on  the 
mucous  membrane  and  thus  makes  possible  infection;  for,  as  we 
have  stated  previously,  bacteria  can  not  live  in  a  bladder  which  is 
lined  with  a  normal  mucosa. 

Symptoms  and  Diagnosis. — The  child  is  restless,  cries  a  great  deal, 
is  pale  and  weak,  has  loss  of  appetite,  and  the  temperature  is  ele- 
vated. There  are  increased  frequency  of  micturition  and  difficulty  in 
passing  urine,  also  colic  in  the  abdomen,  with  tenderness  on  press- 
ure over  the  bladder.  The  urine  is  generally  acid,  cloudy,  and  of 
strong  odor.  The  sediment  under  the  microscope  is  seen  to  contain 
much  pus,  free  and  in  clumps,  and  many  squamous  epithelial  cells 
from  the  bladder,  also  blood  and  bacteria.  Through  the  cystoscope 
the  mucosa  is  seen  to  be  reddened,  swollen,  and  covered  with  mucus. 
It  may  be  excoriated  and  show  ulcerations  and  clotted  blood.  In 
the  tuberculous  form  there  are  fibrinous  deposits  on  the  surface 
of  the  mucous  membrane  and  cultures  made  from  the  deposit 
determine  the  sort  of  bacterium  present. 

STONE  IN  THE  BLADDER. — As  already  pointed  out,  this  is  rare  in 
the  female.  There  are  certain  parts  of  the  United  States  where 
it  is  relatively  common,  such  as  Kentucky,  Tennessee,  Ohio, 
Virginia,  and  North  Carolina.  The  calculi  are  mostly  composed  of 
uric  acid.  Next  in  frequency  are  oxalate  of  lime,  and  sometimes 
there  is  found  urate  of  ammonium  combined  with  uric  acid. 

The  symptoms  are  sudden  stoppage  of  the  stream  of  urine  during 
micturition,  vesical  tenesmus,  cloudy  and  strong-smelling  urine, 
and,  in  older  children,  pain  in  the  bladder  region  on  jumping  or 
playing  violently.  The  diagnosis  is  made  by  passing  the  sound  into 
the  bladder  and  noting  the  metallic  click  caused  by  bringing  it  in 
contact  with  the  calculus. 

Primary  Tumor  of  the  Bladder. — G.  Hiisler  (Jahrbuch  fur 
Kinderheilk.,  190"),  Vol.  62,  p.  33)  has  collected  from  the  literature 


DISEASES  OF  THE  BLADDER  583 

three  primary  tumors  of  the  bladder  in  female  infants  aged,  respec- 
tively four,  nine,  and  seven  months;  the  symptoms  being  a  sudden 
retention  of  urine  followed  by  cystitis  with  bloody  urine.  One  of 
the  tumors  was  a  spindle-celled  sarcoma,  another  fibroadenoma, 
and  the  third  of  unknown  character.  In  the  same  list  with  these 
three  cases  were  eleven  instances  of  tumor  of  the  bladder  in  boys, 
showing  the  relative  frequency  of  this  rare  disease  in  the  two  sexes. 

Hematuria. — By  hematuria  is  meant  the  excretion  of  urine 
containing  blood.  This  affection  is  to  be  distinguished  from 
hemoglobinuria,  the  discharge  of  blood-coloring  matter  in  the 
urine.  In  the  latter, — a  disease  caused  by  the  toxemias  and  found 
especially  in  scarlet  fever,  also  in  measles,  typhoid  fever,  erysipelas, 
and  malaria, — the  red  blood  corpuscles  are  not  found  by  the  mi- 
croscope in  the  urine. 

Blood  in  the  urine  is  purely  symptomatic  and  may  be  due  to 
local  causes,  such  as  stone  in  the  kidney  or  bladder  tuberculosis, 
or  tumor  of  the  kidney ;  or  to  general  causes,  such  as  a  hemorrhagic 
diathesis;  and  most  frequent  of  all,  infantile  scurvy.  The  vagina 
as  a  source  of  blood  must  be  excluded  always  by  a  local  examination. 
The  presence  of  blood  casts  in  the  urine  is  a  sure  sign  that  the 
blood  comes  from  the  kidney  and  the  presence  of  casts  of  other 
sorts  and  renal  epithelium  points  toward  the  kidney  as  a  source. 
In  these  cases  the  blood  will  be  found  to  be  intimately  mixed  with 
the  urine  and  clots  are  rare. 

As  early  as  1889,  Gee  (St.  Barthol.  Hosp.  Reports,  1889,  Vol. 
XXV.,  p.  85)  first  called  attention  to  bloody  urine  as  often  the  only 
sign  of  infantile  scurvy,  and  more  recently  J.  L.  Morse  (Journ. 
Amer.  Med.  Asso.,  Dec.  17,  1904)  has  insisted  on  the  importance  of 
this  symptom  in  scurvy,  reporting  seven  cases  seen  by  him  in  the 
course  of  three  years.  He  considers  that  hematuria  may  be  the 
earliest  symptom  of  infantile  scurvy  and  therefore,  for  a  time,  the 
only  symptom,  and  it  is  the  most  common  cause  of  uncomplicated 
hematuria  in  infancy.  J.  P.  Parkinson  (Brit.  Med.  Journ.  of  Chil. 
Dix.,  Fob.  1907,  p.  37)  has  reported  a  case  of  infantile  scurvy  in  a 
child  eleven  and  one-half  months  old,  in  which  hematuria  was  the 
only  obvious  sign  of  the  disease  until  closer  examination  showed 
other  signs. 

There  arc  a  few  cases  on  record  of  hematuria  due  to  the  ad- 
ministration of  sulicylato  of  soda  by  the  mouth,  notably  that  of 


584  INFANCY  AND  CHILDHOOD 

Marshall,  which  appeared  in  the  Lancet  for  February  2,  1907, 
where  a  girl  of  ten  had  homaturia  following  the  taking  of  small 
doses  of  the  salicylate.  Chlorate  of  potash,  rhubarb,  and  straw- 
berries have  been  known  to  cause  hematuria. 


DISEASES  OF  THE  RECTUM 

Attention  has  been  called  to  imperforate  anus  and  rectum  in 
infants  in  the  consideration  of  the  anomalies,  page  561. 

Practically  all  of  the  diseases  of  the  rectum  found  in  the  adult 
are  found  also  in  the  child  since,  more  particularly  in  recent  years, 
the  pediatrists  have  studied  the  affections  in  children.  We  shall 
mention  here  only  the  more  common  ones. 

Prolapse  of  the  Rectum. — A  portion  or  the  whole  of  the  rectum 
may  be  everted  through  the  anal  orifice.  The  prolapse  is  said  to 
be  partial  when  the  mucous  membrane  alone  is  extruded,  and 
complete  when  all  the  coats  of  the  rectum  are  involved.  Rectal 
prolapse  occurs  slightly  more  often  in  girls  than  in  boys.  According 
to  Bokai's  statistics  of  360  collected  cases,  163  were  in  male  and 
197  in  female  infants.  The  affection  is  most  frequent  in  children 
during  the  second  and  third  years  of  life,  probably  because  at  this 
time  the  child  is  put  on  the  chamber  and  straining, — particularly 
in  those  conditions  in  which  straining  is  excessive,  such  as  dysentery, 
—brings  the  intra-abdominal  pressure  more  directly  on  the  loosely 
fixed  rectum.  This  is  brought  about  by  the  lack  of  curve  in  the 
sacrum  in  the  infant,  thus  permitting  of  more  direct  abdominal 
pressure  from  above,  and  less  protection  for  the  rectum  from  below 
and  behind  by  the  cartilaginous  coccyx  than  is  the  case  in  the 
adult  where  the  lower  rectum  is  protected  by  the  strongly  curved 
bony  coccyx. 

Predisposing  causes  are  wasting  diseases,  such  as  rickets  and 
diseases  of  the  intestine.  Enteritis  and  proctitis,  obstinate  consti- 
pation, stone  in  the  bladder,  and  whooping-cough  have  been  known 
to  stand  in  causal  relationship  to  prolapse. 

Prolapse  usually  occurs  during  the  act  of  defecation.  The 
physician  notes  a  bright  red  tumor,  covered  with  mucus  and 
the  size  of  a  walnut,  at  the  anus.  It  is  generally  easily  reduced, 
but  returns  with  each  movement  of  the  bowels,  gradually  increasing 


DISEASES  OF  THE  RECTUM  585 

in  size.  Sometimes  the  application  of  cold  to  the  prolapse  will 
cause  it  to  go  back.  In  the  more  extensive  grades  of  prolapse  the 
tumor  may  be  the  size  and  shape  of  a  small  potato — conical  in  shape, 
with  the  dimple  of  the  opening  of  the  bowel  at  its  apex,  similar  to 
the  external  os  in  the  case  of  uterine  prolapse.  The  symptoms  of 
prolapse  besides  protrusion  are,  loss  of  control  over  the  action 
of  the  bowels, — shown  by  the  baby's  napkins  being  always  soiled, — 
increased  frequency  of  the  action  of  the  bowels,  and,  in  cases  of  a 
severe  grade,  bleeding  of  small  amount  from  the  prolapsed  mucous 
membrane. 

Proctitis. — Inflammation  of  the  rectum  occurs  in  children  as  a 
part  of  inflammation  of  the  rest  of  the  large  intestine,  but  may 
occur  (rarely)  alone.  The  causes  are  chiefly  local,  the  most  frequent 
being  the  use  of  irritating  injections  or  suppositories,  either  to 
combat  constipation  or  for  the  administration  of  drugs.  Proctitis 
accompanies  thread-worms  and  is  found  in  cases  of  gonorrheal 
vulvo-vaginitis  from  extension  of  the  infection  from  the  vulva, 
either  spontaneously  or  by  the  introduction  of  the  nurse's  or  mother's 
finger,  or  a  syringe  tube  through  the  anus  during  the  course  of  this 
disease.  Both  simple  catarrhal  and  specific  proctitis  have  been 
observed.  (See  Chapter  XXVI.,  page  506.) 

Fissure  in  Ano. — This  is  not  very  rare  in  children  and  is  caused 
by  the  passage  of  large,  hard  fecal  masses,  or  by  the  maladroit  use 
of  the  syringe  nozle.  The  result  of  the  injury  of  the  mucosa  of 
the  anal  canal  is  an  irritable  ulcer  situated  in  one  of  the  folds  of 
the  mucous  membrane,  pear-shaped  or  triangular  hi  form,  with 
its  long  axis  in  the  long  axis  of  the  anal  canal.  Pain  on  defecation 
is  the  constant  symptom.  The  child  cries  and  resists  every  effort 
to  have  the  bowels  move,  so  that  chronic  constipation  results. 
The  pain  may  be  referred  to  other  parts  in  the  neighborhood. 
The  ulcer  is  felt  by  the  well-anointed  finger  passed  into  the  anus 
as  a  rough  spot  and  it  is  seen  by  introducing  a  large  Kelly  cysto- 
scope  (No.  12)  through  the  sphincter  and  inspecting  the  surface  of 
the  mucous  membrane  as  it  rolls  into  the  lumen  of  the  cystoscope 
as  the  instrument  is  withdrawn. 

Incontinence  of  Feces. — Incontinence  of  feces  is  a  symptom  of 
prolapse  of  the  rectum.  It  is  seen  in  cases  similar  to  incontinence 
of  urine  in  children  who  are  over  three  years  of  age,  and  may  be 
associated  with  the  latter  affection.  Fowler  (Amer.  Journ.  Obstet., 


586  INFANCY  AND  CHILDHOOD 

1882,  XV.,  p.  984)  mentions  the  case  of  a  girl  of  thirteen  years  in 
whom  incontinence  of  feces  had  persisted  from  infancy.  In  this 
case  the  sphincter  ani  was  decidedly  relaxed.  A.  Riviere  (Mede- 
cine  moderne,  1898,  Vol.  IX.,  p.  308)  reports  the  case  of  a  girl  of 
twelve  years,  where  incontinence,  beginning  at  nine  years,  was  due 
to  chronic  overdistention  of  the  rectum.  The  rectum  in  this  case 
was  found  to  be  greatly  distended. 

The  cause  of  this  affection  is  generally  clearly  an  affair  of  the 
nervous  system,  just  as  in  the  case  of  enuresis.  According  to  the 
reported  cases  it  occurs  more  frequently  in  boys  than  in  girls. 

Incontinence  of  feces  is  found  in  cases  of  chronic  wasting  diseases, 
epilepsy,  myelitis,  and  in  injury  to  the  lumbar  portion  of  the  spinal 
cord ;  also  in  meningitis,  and  occasionally  in  typhoid  fever.  In  all 
cases  not  of  manifest  central  nervous  origin  the  sphincter  ani 
should  be  examined  as  to  its  tonicity,  and  also  a  proctoscopic  ex- 
amination of  the  rectum  should  be  made  to  detect  overdistention 
and  relaxation  of  that  organ. 


CHAPTER  XXIX 

THE  MENOPAUSE  AND  OLD  AGE 

The  menopause,  p.  587:  General  considerations,  p.  588.  Anatomical 
and  physiological  considerations,  p.  592;  Anatomy,  p.  592.  Atrophic 
changes  in  the  uterine  organs,  p.  594;  Physiology,  p.  595.  Age  at  which 
the  menopause  occurs,  p.  597.  Premature  menopause,  p.  598.  Delayed 
menopause,  p.  601.  The  dodging  time,  p.  611.  Phenomena  of  the  meno- 
pause in  body  and  mind,  p.  612;  Cardio-vascular  system,  p.  612,  Hot 
flashes,  p.  612,  Tachycardia  and  high  arterial  tension,  p.  613;  The  nervous 
system,  p.  613;  Sexual  feelings,  p.  614;  Mental  diseases,  p.  615;  The 
alimentary  canal,  p.  615;  The  nutrition,  p.  616;  Rheumatism,  p.  616;  The 
skin,  p.  617.  Influence  of  uterine  diseases  on  the  menopause,  p.  617; 
Hemorrhages,  p.  617;  (a)  Fibroids,  p.  617;  (6)  Subinvolution,  p.  618; 
(c)  Endometritis,  p.  618;  (d)  Polypi,  p.  618;  (e)  Cancer  of  the  uterus,  p. 
619;  Displacements  of  the  uterus,  p.  620;  Cystocele  and  rectocele,  p.  621; 
Vaginitis  and  injuries  of  the  vagina  from  coitus,  p.  621 ;  Eczema  or  pruritus 
vulvse,  p.  621;  Vesical  symptoms,  p.  621. 

Old  age,  p.  622 :  General  considerations,  p.  622 :  Effects  of  old  age  on 
the  ovaries,  p.  623;  On  the  Fallopian  tubes,  p.  623;  On  the  uterus,  p.  624; 
On  the  vagina,  p.  625;  On  the  vulva,  p.  625. 

THE  menopause  (,«£ve? ,  menses,  and  raD^?,  cessation)  sometimes 
called  the  change  of  life,  or  climacteric,  the  time  when  the  cata- 
menia  cease,  marks  not  only  the  end  of  the  reproductive  period 
in  the  life  of  woman,  but  it  means  also  a  change  hi  the  psychical  as 
well  as  in  the  bodily  make-up  of  the  individual.  It  occurs  in  tem- 
perate climates  after  a  period  of  from  thirty  to  thirty-two  years  of 
menstrual  life,  between  the  ages  of  forty-five  and  fifty  years.  Then 
ensues  a  period  of  rejuvenescence  of  ten  or  fifteen  fyears  in  which 
the  woman,  freed  from  the  annoyances  and  disturbing  influences  at- 
tendant on  menstruation  and  childbearing,  settles  into  a  more  staid 
and  less  emotional  form  of  life,  when  she  devotes  herself  to  the  duties 
and  problems  that  confront  her  without  the  demands  on  her  strength 
that  reproduction  or  preparation  for  reproduction  entail. 

As  regards  old  age  it  becomes  necessary  at  the  outset  to  dis- 
tinguish between  the  general  application  of  the  term  to  the  latter 
part  of  life  and  that  portion  of  it  in  which  there  are  present  distinct 
evidences  of  degeneration  of  body  or  mind.  Perhaps  the  latter 
time  is  more  accurately  defined  by  the  term  senility.  That  some 
individuals  maintain  vigor  of  both  body  and  mind  even  to  ad- 
vanced years,  is  common  observation,  so  that  placing  a  mark  in 

587 


5SS  THE  MENOPAUSE  AND  OLD  AGE 

number  of  years  for  the  beginning  of  senility  is  a  manifestly  difficult 
proceeding.  The  ancients  said, — "/Etas  non  annis  sed  viribus 
lestimatur."  Nevertheless,  Hippocrates  placed  the  beginning  of 
senility  at  fifty-six  years;  Daubenton,  who  lived  in  the  eighteenth 
century,  at  sixty-three,  and  Flourens  ("De  la  longevite,"  1854), 
some  hundred  years  later,  at  seventy.  Most  authors  adopt  a  con- 
ventional age  of  sixty  as  the  beginning  of  the  retrogressive  changes 
of  old  age,  and  we  will  follow  their  lead. 


THE  MENOPAUSE 

GENERAL  CONSIDERATIONS 

The  term  menopause,  although  signifying  only  the  cessation  of 
the  menses,  is,  on  the  whole,  the  best  we  have  to  describe  a  com- 
plex condition.  Whether  the  catamenia  cease  suddenly  or  by 
irregularly  recurring  periods  scattered  over  a  number  of  months 
or  years,  the  stopping  of  the  menses  is  only  one  symptom  attend- 
ing changes  not  only  in  the  reproductive  organs,  but  also  in  many 
other  organs  and  in  the  system  at  large,  these  changes  having 
their  origin  in  a  cessation  of  the  function  of  the  ovaries.  The 
symptoms  consist  roughly  of  the  following: — On  the  part  of  the 
uterus,  hemorrhages  and  leucorrhea;  the  heart,  palpitation  and 
irregular  rhythm;  the  arteries,  increased  tension  and  hot  flashes;  the 
nervous  system,  neuralgias,  insomnia,  depression  of  spirits,  and  ner- 
vous instability;  the  alimentary  tract,  dyspepsia,  gastro-enteritis, 
and  constipation;  the  kidneys,  renal  insufficiency;  the  skin,  derma- 
toses;  and  the  general  nutrition,  obesity,  rheumatism,  and  anemia. 

Among  the  savages,  who  lead  an  out-of-door  life  and  are  the  least 
removed  in  their  mode  of  existence  from  the  animals,  it  would 
appear  that  the  menopause  occurs  without  any  symptoms  except 
the  cessation  of  menstruation.  (A.  Currier,  Amer.  Gyn.  Trans., 
Vol.  16,  1891.)  Among  the  civilized  races,  however,  the  more 
artificial  the  life  the  more  likely  the  occurrence  of  one  or  more  of 
the  symptoms  enumerated.  In  fact,  the  absence  of  symptoms 
during  the  change  of  life  may  be  regarded  as  abnormal  among 
women  of  all  classes  and  conditions  of  life  in  civilized  communities 
to-day.  This  should  not  be  construed  as  meaning  that  the  meno- 
pause is  a  critical  time  of  life  or  that  the  gloomy  views  about  this 


THE  MENOPAUSE  589 

period  that  obtained  in  ancient  times,  or  even  thirty  or  forty  years 
ago,  should  be  held  true  at  the  present  time.  For  instance,  Kisch 
("Das  klimakterische  Alter  dcr  Frauen,"  1874,  p.  109),  writing  in 
1874,  gives  the  following  table  of  gynecological  affections  he  found 
in  440  women  who  complained  of  symptoms  referable  to  the  uterine 
organs,  among  five  hundred  women  investigated,  in  many  cases 
several  diseases  being  found  in  one  individual: — 

Cases 

Menorrhagia  and  metrorrhagia  in 286 

Chronic  metritis 79 

Leucorrhea 327 

Prolapsus  uteri    65 

Ante-  and  retroflexion  of  uterus 52 

Pruritus  vagina3 46 

Vaginismus 12 

Carcinoma  uteri 3 

Uterine   polyp 5 

Tumor  of  the  breast 8 

Tilt  ("The  Change  of  Life,"  E.  J.  Tilt,  1882,  p.  143)  has  an 
even  longer  list  of  uterine  diseases  found  in  five  hundred  women, 
as  follows: — 

Cases 

Floodings,  in 138 

Leucorrhoea 158 

Remittent  menstruation 33 

Vaginitis 4 

Follicular  inflammation  of  the  vulva 10 

Inflammation  of  the  labia 4 

Ulceration  of  the  neck  of  the  womb 9 

Hypertrophy  and  inflammation  of  the  womb 2 

Prolapsus  of  the  womb 5 

Uterine  polypi 4 

Uterine  fibrous  tumors 4 

Uterine  cancer 4 

Ovarian  tumors 3 

Milky  or  glutinos  secretion  of  the  breasts    2 

Irritation  and  swelling  of  the  breasts 14 

Tumor  of  the  breast,  non-malignant 2 

Cancer  of  the  breast 1 

Habitual  deposits  in  the  urine 49 

Pain  and  difficulty  in  passing  urine 9 

Incontinence  of  urine 4 

Haematuria     1 

Erectile  tumor  of  the  meatus  urinarius 2 

Perineal   abscess 2 

464 


590  THE  MENOPAUSE  AND  OLD  AGE 

The  earlier  writers  believed  that  many  maladies  of  serious 
nature  were  necessarily  due  to  the  menopause  and  this  view  is 
still  held  by  many,  not  only  of  the  general  public,  but  by  members 
of  the  medical  profession.  The  reason  is  to  be  found  in  the  absence 
of  accurate  diagnosis  in  the  past.  For  instance,  take  the  uterine 
disease,  fibroid  tumor  of  the  uterus.  We  know  now  that  these 
tumors  are  the  cause  of  a  very  large  number  of  cases  of  flowing  at 
the  menopause,  and  further  that,  unless  there  is  surgical  interference, 
the  cessation  of  the  menses  in  these  cases  does  not  come  for  several 
years  after  the  time  observed  in  women  who  have  no  uterine  disease. 
Fibroid  cases  were  formerly  included  in  the  statistics  of  the  meno- 
pause, whereas  now  they  are  treated  surgically  so  often  and  are 
generally  recognized  as  fit  subjects  for  operative  treatment,  that  no 
one  thinks  of  leaving  them  to  the  kind  offices  of  nature  unassisted. 
The  early  recognition  of  uterine  cancer  was  an  unknown  branch  of 
diagnosis  fifty  years  ago  and  instances  of  flowing  caused  by  this 
dread  disease  were  classed  as  natural  concomitants  of  the  climacteric. 
Now  we  know  that  cancer  is  found  most  frequently  in  both  sexes 
between  the  ages  of  forty-five  and  fifty-five  and  there  is  reason  to 
believe  that  the  disease  has  some  association  with  retrogressive 
changes  in  the  tissues. 

At  all  events  this  holds  true  in  the  case  of  cancer  of  the  breast 
where  the  atrophy  of  the  tissues  of  the  breast  at  the  menopause 
is  associated  with  the  development  of  cancer  in  that  organ.  It  is 
more  than  probable  that  the  same  may  hold  true  of  the  uterus. 
Fibroids  and  cancer  of  the  uterus  are,  therefore,  truly  diseases  of 
the  menopause,  although  the  causative  relations  of  the  climacteric 
to  these  diseases  is  by  no  means  proved,  consequently  they  should 
be  always  in  the  mind  of  the  practitioner  while  considering  the 
case  of  a  woman  who  is  passing  through  this  period  of  life.  The 
point  to  keep  in  mind  in  this  connection  is  that  it  is  the  uterine 
disease  that  causes  the  patient's  ill  health  and  not  the  time  of  life 
during  which  the  disease  manifests  itself,  in  the  same  measure 
as  regards  the  constitutional  diseases.  Tilt  mentions  in  his  table 
forty-nine  cases  of  "habitual  deposits  in  the  urine."  Now  we 
look  for  faults  in  metabolism  and  a  diminished  ingest  ion  of  fluids 
to  explain  such  deposits. 

In  a  study  of  the  menopause  for  the  purpose  of  gaining  an  in- 
sight into  its  true  nature,  one  considers  first  the  physiology  of  the 


THE  MENOPAUSE  591 

change  of  life  in  a  normal  woman  and  then  the  points  of  departure 
from  the  normal.  If  such  a  thing  were  possible  we  should  utilize 
statistics  of  the  symptoms  manifested  by  women  having  normal 
uterine  organs  when  they  are  passing  through  the  period  of  the 
change.  Most  of  the  figures  given  by  writers  on  this  subject,  such 
as  Brierre  de  Boismont,  Kisch,  Kehrer,  Tilt,  and  Borner,  are  made 
up  largely  of  women  suffering  with  uterine  diseases.  Normal 
women  do  not  apply  to  physicians  for  advice,  and  whatever  symp- 
toms they  experience  are  not  a  matter  of  record,  or  are  not  sub- 
jected to  expert  analysis;  therefore,  most  of  our  ideas  must  come 
from  study  of  abnormal  women  and  chiefly  from  those  who  are 
affected  with  uterine  disease.  The  many  variations  in  general 
health  exhibited  by  women  who  arc  undergoing  the  menopause 
complicate  an  investigation  into  the  phenomena  and  therefore 
hinder  the  sifting  of  cause  and  effect. 

During  the  last  twenty  years,  since  abdominal  operations  on  the 
uterine  organs  have  become  so  common,  frequent  opportunities 
have  presented  for  more  accurate  study  of  the  condition  of  these 
organs  during  and  subsequent  to  the  menopause.  Moreover,  our 
knowledge  of  the  artificial  menopause,  induced  by  the  removal  of 
the  ovaries,  has  become  very  minute  of  late  years,  because  of  the 
unfortunate  practice  which  obtained  in  the  eighties  and  nineties  of 
removing  the  ovaries  for  the  cure  of  a  variety  of  diseases  of  the 
nervous  system,  and  also,  since  the  era  of  aseptic  abdominal  oper- 
ating began,  the  frequent  sprayings  made  necessary  by  ovarian 
disease  have  furnished  many  examples. 

In  this  chapter  I  shall  approach  the  subject  of  the  menopause 
from  the  standpoint  of  the  gynecologist,  citing  first  the  opinions 
of  the  most  eminent  authorities  and  then  my  own  views  formed  by 
reading  the  literature  and  by  an  analysis  of  one  hundred  and  fifteen 
cases  taken  from  my  private  case  records  of  women  who  were 
between  the  ages  of  forty-one  and  fifty-nine  years,  who  had  either 
passed  by  the  menopause  or  were  passing  through  it,  all  of  the  cases 
being  women  who  consulted  me  for  uterine  disease.  No  cases  of 
myoma  or  cancer  arc  included  except  a  few  cases  of  small  uterine 
polypi  which  may  have  been  of  myomatous  origin,  and  a  few  cases 
of  cancer  of  the  uterus  which  were  several  years  past  the  meno- 
pause. 


592  THE  MENOPAUSE  AND  OLD  AGE 

ANATOMICAL  AND  PHYSIOLOGICAL  CONSIDERATIONS 

Anatomy. — The  ovaries  are  developed  in  the  embryo  from  epi- 
blast  antl  mesoblast  on  the  inner  surface  of  the  Wolffian  bodies  in 
close  relationship  with  Mailer's  ducts,  which  eventually  form  the 
Fallopian  tubes,  uterus,  and  vagina.  Most  of  the  ovary  is  composed 
of  cortex,  which  is  made  up  of  primary  ova  enclosed  in  primary 
follicles  which  lie  in  a  delicate  connective-tissue  framework.  At 
birth  there  are  some  one  hundred  thousand  of  these  primary  ova 
present  in  an  ovary,  over  half  of  them  disappearing  before  puberty 
is  reached,  and  the  rest  developing  into  ripened  ova  in  their  Graafian 
follicles  to  be  constantly  diminished  in  number  during  the  thirty  or 
thirty-two  years  of  sexual  maturity  by  the  repeated  discharge  of 
ova  through  the  surface  of  the  ovary,  leaving  it,  as  the  years  go 
by,  with  an  ever-increasingly  corrugated  appearance. 

After  the  ovum  has  escaped  from  the  Graafian  follicle  there  is 
formed,  on  the  inner  surface  of  the  walls  of  the  follicle,  the  corpus 
luteum,  a  wrinkled  yellow  membrane  made  up  of  polygonal  epithe- 
lioid  lutein  cells,  the  yellow  color  being  due  to  the  lutein.  If  preg- 
nancy supervenes  the  corpus  luteum  persists  for  a  long  time;  if  it 
does  not,  connective  tissue  takes  the  place  of  the  lutein  cells,  the 
yellow  color  disappears,  and  the  corpus  is  gradually  absorbed. 

When  the  menopause  has  been  established  the  cortical  zone  of 
the  ovary  is  diminished  in  thickness,  the  ova  and  their  follicles 
disappear,  and  the  ovary  becomes  progressively  smaller  in  size 
and  more  shrunken  in  appearance  as  the  connective  tissue,  of 
wliich  it  is  now  mainly  composed,  atrophies  with  the  advancing 
years. 

The  office  of  the  ovary  is  to  furnish  ova,  and  in  addition  it  has 
an  important  influence  on  various  functions  of  the  body,  chiefly 
the  circulation  of  the  blood,  the  nervous  system,  and  the  nutrition. 
The  theory  has  been  suggested  by  various  observers  that  the 
ovaries  are  ductless  glands  like  the  thyroid  and  suprarenal  glands 
and  that  they  furnish  an  internal  secretion.  .More  recently  the 
view  has  gained  ground  that  this  internal  secretion  is  produced  by 
the  corpus  luteum.  This  is  not  the  place  to  discuss  the  various 
theories  and  the  facts  advanced  to  substantiate  them.  Suffice  it 
to  say  that  as  yet  we  know  nothing  more  than  probabilities  and  these 
seem  to  me  to  be  that  the  ovaries  exercise  their  influence  on  the 


THE  MENOPAUSE  593 

system  chiefly  through  the  circulation,  an  argument  in  favor  of 
the  theory  of  an  internal  secretion. 

The  function  of  the  thyroid  gland  seems  to  have  some  relation  to 
that  of  the  ovary,  both  being  in  sympathy  as  essential  to  the  develop- 
ment and  preservation  of  the  genital  organs,  and  yet  opposed  in 
certain  respects,  as  shown  by  the  enlargement  of  the  thyroid  at 
the  menopause.  Thyroid  feeding  produces  excellent  results  hi 
cretinism  and  in  infantilism,  and  ovarian  extract  ameliorates  the 
symptoms  of  exophthalmic  goitre.  Vinay  ("  La  menopause,"  1908, 
p.  60)  points  out  that  in  parts  of  Switzerland  where  goiters  are 
common,  many  women  develop  these  tumors  for  the  first  time  at  the 
menopause,  but  not  before  or  after.  The  suprarenal  glands  have 
been  found  hypertrophied,  or  the  seat  of  tumor  formation,  in  cases 
of  sexual  precocity;  and  atrophy  has  been  found  associated  with 
insufficient  development  of  the  genital  organs,  so  we  are  led  to  be- 
lieve that  these  organs  have  an  intimate  relationship  with  the 
ovaries. 

Hegar  likened  the  tubes,  uterus,  and  vagina  to  the  duct  of  a  gland, 
the  ovary.  Disappearance  of  this  gland  results,  as  in  similar 
processes  in  other  glands,  in  disappearance  of  the  duct  also.  So  in 
the  developmental  stage  of  the  organism  the  growth  of  the  duct  is 
related  to  that  of  the  gland,  and  when  hi  anomalies  the  ovaries  are 
found  absent,  the  tubes  and  uterus  or  the  vagina  are  generally 
either  defective  or  wanting.  At  the  time  of  the  menopause  the 
atrophy  of  the  ovary  is  accompanied  not  only  by  a  cessation  of 
menstruation,  but  by  a  shrinking  of  the  tubes,  uterus,  vagina,  and 
external  genitals,  all  a  slow  process  requiring  a  variable  amount  of 
time  in  different  individuals,  but  always,  in  all  probability,  a  series 
of  months  or  years. 

In  the  following  case  reported  by  J.  C.  Dalton  (Trans.  Amer. 
Gijn.  Soc.,  1878,  Vol.  2,  p.  134),  the  ovaries  one  year  after  the 
menopause  showed  Graafian  follicles  in  a  state  of  degeneration, 
and  no  corpora  lutea:— "A  woman,  forty-three  years  of  age,  of 
average  bodily  development,  who  had  had  one  child  twenty-one 
years  before,  died  at  the  Charity  Hospital,  New  York,  February  7, 
1877,  of  cerebral  meningitis.  Menstruation  had  ceased  within  a 
few  days  of  one  year  before  death. 

"The  uterus  was  empty,  of  medium  size,  and  normal  in  appearance 
except  for  a  constriction  of  the  os  internum,  which  was  reduced  to 
38 


594  THE  MENOPAUSE  AND  OLD  AGE 

an  orifice  two  millimeters  in  diameter.  The  uterine  mucous  mem- 
brane was  generally  smooth  and  pale,  marked  only  with  a  slight 
arborization  of  fine  blood-vessels.  The  ovaries  were  somewhat 
undersized,  and  loose  in  texture.  They  contained  a  number  of 
collapsed,  empty,  degenerate  Graafian  follicles  with  slightly  thick- 
ened walls,  presenting  the  appearance  of  having  been  long  in  an 
inactive  condition.  One  ovary  contained  ten  or  fifteen  such  bodies, 
the  other  from  fifteen  to  twenty.  In  the  ovarian  tissue  there  were 
also  a  few  small,  blackish  stains,  without  definite  structure.  There 
were  no  normal  Graafian  follicles  anywhere,  and  no  corpora  lutea 
in  either  organ." 

In  contrast  to  this  case  Puech  (cited  by  E.  Borner,  "DieWech- 
seljahrc  der  Frau,"  1886,  p.  8)  found  the  ovaries  of  normal  size  in  a 
woman  three  years  after  the  menopause.  In  my  own  list  of  cases 
(Case  No.  17,  see  table  on  page  605)  I  removed  atrophic  ovaries 
from  a  single  woman  forty-one  years  of  age  before  the  menopause 
had  become  established,  although  the  patient  had  been  in  the 
dodging  time  for  two  years;  whereas  in  Case  60,  that  of  a  married 
woman  of  forty-six,  the  ovaries  were  normal  in  size  and  appear- 
ance at  operation  one  year  after  the  beginning  of  irregularity  of 
the  menses.  As  a  rule  I  have  found  the  ovaries  atrophied  at  opera- 
tions performed  on  patients  who  have  passed  the  menopause  (as  in 
Case  108)  except  in  cases  where  the  ovaries  with  their  tubes  were 
the  seat  of  a  chronic  inflammatory  process. 

Atrophic  Changes  in  the  Uterine  Organs. — During  and  following 
the  cessation  of  menstruation  retrograde  metamorphosis  takes 
place  in  the  ovaries,  the  Fallopian  tubes,  the  uterus,  the  vagina, 
and  the  external  genitals,  the  process  of  atrophy  of  these  organs 
requiring  a  variable  amount  of  time  in  different  individuals  and 
proceeding  with  the  same  rate  of  speed  in  the  different  organs  in  no 
two  patients  alike.  In  the  absence  of  definite  demonstrable  patho- 
logical conditions  the  atrophic  changes  should  proceed  from  the 
ovaries  downward,  involving  in  progressive  sequence  tubes,  uterus, 
vagina,  and  external  genitals,  and  this,  I  think,  is  the  rule.  The 
tubes  lose  their  lining  epithelium  and  finally  their  lumen  is  closed 
and  they  become  mere  cords;  the  uterus  becomes  smaller  in  all  its 
dimensions,  its  walls  grow  thinner,  and  the  internal  os  is  contracted 
and  is  often  obliterated.  The  cervix  generally  atrophies  before 
the  body  of  the  uterus,  becoming  shorter  and  thinner,  but  in  women 


THE  MENOPAUSE  595 

who  have  regular  sexual  intercourse  this  may  not  be  the  case,  and 
of  course,  if  the  cervix  is  the  seat  of  old  lacerations  and  chronic 
metritis,  it  may  be  the  last  portion  of  the  organ  to  show  atrophic 
changes. 

When  the  menopause  is  well  established  the  vagina,  which 
during  the  change  is  apt  to  be  hyperemic,  becomes  pale, — perhaps 
only  in  patches,  while  the  rest  is  dark  red;  it  is  narrower  and 
shorter  and  assumes  a  conical  shape  because  the  contraction  is 
greatest  in  the  upper  portion.  It  loses  its  elasticity  and  the  mucous 
membrane  gradually  is  deprived  of  its  ruga?,  so  that  the  walls 
become  more  friable  and  the  surface  smoother.  Sometimes  coitus 
hi  the  case  of  an  atrophic  vagina  causes  excoriation,  pain,  and 
bleeding,  and  may  be  the  source  of  impairment  of  the  nervous 
balance  of  the  patient.  Laxity  of  the  tissues  of  the  vagina  with 
atrophy  of  the  muscular  walls  at  the  menopause  favors  prolapse. 

The  changes  in  the  external  genitals  consist  in  loss  of  subcutaneous 
fat  and  in  a  gradual  shrinking,  but  these  transformations  are  so 
closely  bound  up  with  the  nutrition  of  the  system  as  a  whole,  that, 
although  having  their  origin  at  the  menopause,  they  are  generally 
not  marked  until  old  age.  Therefore,  we  seldom  note  absence  of 
fat  under  the  mons  veneris  and  the  labia  pudendi  until  old  age  sets 
in,  even  in  the  cases  of  premature  and  artificially  induced  menopause. 
The  condition  here  is  not  dissimilar  to  that  hi  the  mammae  which 
atrophy  at  the  menopause,  the  gland  tissue  being  replaced  by 
fatty  tissue,  which  is  deposited  in  abundance  throughout  the 
entire  body,  especially  in  its  upper  portions,  at  this  time. 

Physiology. — To  obtain  an  understanding  of  the  physiology  of 
menstruation  it  seems  to  me  that  the  menstrual-wave  theory 
developed  by  Mary  Putnam  Jacobi  ("On  the  Question  of  Rest  for 
Women  (luring  Menstruation,"  1878)  and  by  William  Stephenson 
(Atucr.  Journ.  Obstet.,  1882,  Vol.  XV,  p.  287)  offers  the  best 
explanation.  It  is  that  menstrual  life  is  associated  with  a  well- 
marked  wave  of  vital  energy  manifested  by  variations  in  the  body 
temperature,  in  the  daily  amount  of  excretion  of  urea,  and  in  the 
arterial  tension,  as  demonstrated  by  the  investigations  of  these 
authors.  The  highest  body  temperature,  the  greatest  daily  ex- 
(Totion  of  urea,  and  the  highest  arterial  tension  as  registered  by 
the  sphygmograph  occur  at  a  period  of  five  or  six  days  before 
menstruation,  and  the  lowest  point  of  all  three  of  these  indices  of 


596  THE  MENOPAUSE  AND  OLD  AGE 

the  vital  processes  is  just  after  the  cessation  of  menstruation.  In 
other  words,  the  woman's  system  is  prepared  by  a  gradual  rhythmic 
process  for  menstruation  and  reproduction.  We  know  that  at  the 
menstrual  period  the  uterus,  ovaries,  tubes,  and  vagina  pass  through 
a  phase  of  increased  functional  activity  and  engorgement  that 
necessitates  an  increased  blood  supply  to  these  organs.  Accordingly 
the  tributary  arteries  dilate  and  the  arteries  of  the  rest  of  the  body,  in 
obedience  to  the  law  of  compensation,  undergo  a  vaso-constriction, 
whence  the  slight  drop  in  arterial  tension  noted  by  Stephenson  in 
the  radial  pulse  just  before  and  during  menstruation.  The  blood 
In  the  pelvic  circulation  is  forced  at  increased  pressure  through 
the  capillaries  of  the  uterus,  with  a  result  that  there  is  hemorrhage 
from  the  endometrium. 

It  is  plain  that  anything  that  profoundly  upsets  the  balance  of 
blood-pressure  upon  which  menstruation  depends  may  cause 
either  an  increase  in  the  flow  or  a  diminution,  or  even  cessation. 
This  upsetting  may  come  through  the  nervous  system,  as  in  the 
case  of  nervous  worry  or  shock,  or  it  may  come  directly  through 
the  circulation.  Dr.  Francis  Hare  (Clinical  Journ. ,  Aug.  29,  1906) 
has  reported  a  case  where  the  inhalation  of  amyl  nitrite  immediately 
checked  a  normal  menstrual  flow,  and  in  the  olden  days  when  our 
forefathers  employed  venesection  as  a  universal  therapeutic  measure 
it  is  reported  that  blood-letting,  in  the  case  of  a  menstruating  woman, 
was  followed  by  the  same  result.  In  one  case  the  blood  was  re- 
moved from  the  pelvis  by  vaso-dilation  of  the  systemic  arteries, 
and  in  the  other  by  abstraction  from  the  general  circulation.  The 
tonicity  of  the  blood-vessels,  of  the  portal  system,  that  great  reser- 
voir of  the  body,  must  have  an  important  influence  on  menstruation, 
and  in  the  future  we  may  look  to  see  results  of  investigations  on 
the  circulation  conducted  to  determine  the  causes  of  greater  or 
less  congestion  of  the  uterine  organs  at  the  catamenia. 

We  may  regard  the  time  between  menstrual  periods  not  as  a 
period  of  rest  from  preparation  for  reproduction,  but  as  a  marshal- 
ing of  the  forces  which  reach  their  acme  just  before  the  molimen, 
then,  after  a  brief  period  of  slack  water,  to  rise  again  to  high  tide, 
with  ever-recurring  regularity  of  rhythm  until  the  stimulus  ceases 
to  emanate  from  the  ovary  and  menstruation  and  the  capacity  for 
reproduction  are  no  more. 


THE  MENOPAUSE  597 

t 

AGE   AT  WHICH  THE   MENOPAUSE  OCCURS 

All  the  statistics  found  in  the  literature  as  to  the  age  of  the 
beginning  of  the  menopause  are  unsatisfactory  because  they  in- 
clude chiefly  women  having  all  sorts  of  uterine  diseases  as  well  as 
those  afflicted  with  various  other  bodily  ailments.  Many  of  the 
statistics  include  the  cases  of  premature  menopause.  For  these 
reasons  the  available  statistics  do  not  represent  fairly  the  average 
age  of  the  occurrence  of  the  menopause,  at  least  among  women 
who  are  not  the  subjects  of  uterine  disease,  for  it  is  my  belief  that 
uterine  disease  is  the  principal  cause  of  prolongation  of  the  men- 
strual function.  As  long  ago  as  1869  E.  Krieger  ("  Die  Menstru- 
ation," p.  171)  gathered  the  statistics  of  six  authors,  of  which  the 
following  is  a  summary: — 

Two  thousand  two  hundred  and  ninety-one  cases  reported  by 
Mayer,  Tilt,  Guy,  Brierre  de  Boismont,  Courty,  and  Puech. 

Between  the  No.  of  Percentage 

years  cases  of  all 

36-40 272 11.87 

41-45 595 25.97 

46-50 940 41.03 

51  55 334 14.58 

Before  35 

or  after  55 150 6.54 

In  this  list  the  greatest  number  of  cases  were  the  women  who 
ceased  to  menstruate  between  the  ages  of  forty-six  and  fifty.  Tilt 
(loc.  cit.,  p.  26)  gives  an  average  age  of  45.7  among  1,082  women 
observed  in  London  and  Paris,  including  the  cases  of  premature 
menopause. 

As  regards  the  influence  of  race  or  locality  on  the  time  of  the 
menopause  we  know  so  little  from  what  sort  of  women  the  statistics 
were  gathered,  and  the  figures  of  different  observers  are  so  much  at 
variance,  that  the  only  conclusion  we  are  justified  in  drawing  is 
that  the  age  is  somewhat  more  advanced  in  the  women  of  the 
higher  latitudes  than  is  the  case  in  those  living  nearer  the  equator; 
and  in  the  Jewish  race  the  menopause  occurs  relatively  early  in 
whatever  part  of  the  world  the  women  happen  to  live.  As  an  ex- 
ample of  the  variability  of  statistics  concerning  neighboring  races 
leading  a  similar  mode  of  life,  we  may  cite  the  following: — 

In   a  study  of  the  menopause  among  the  American  Indians 


598  THE  MENOPAUSE  AND  OLD  AGE 

Andrew  F.  Currier  (Trans.  Amer.  Gyn.  Soc.,  1891,  Vol.  16,  p.  274) 
found  an  average  age  of  47.2  among  twenty-five  Sioux  Indians, 
and  53.4  among  ten  of  the  Cheyenne  and  Arapahoe  tribes.  He  states 
(loc.  cit.,  p.  277)  that  among  the  Quapaws  the  child-bearing  period 
ends  at  thirty-five  to  forty,  whereas  among  the  Crows  and  Assini- 
boines  (loc.  cit.,  p.  278)  the  child-bearing  period  frequently  con- 
tinues until  the  forty-fifth  year.  Tilt  gives  a  table  of  the  compara- 
tive dates  of  the  cessation  of  menstruation  in  different  countries 
as  follows: — France,  Paris,  44,  Rouen,  48.7;  England,  46.1  and 
47.5;  Central  Germany,  47;  Denmark,  44.8;  Norway,  48.9;  Lap- 
land, 49.4;  Russia,  45.9. 

Something  must  be  assigned  to  the  influence  of  heredity  in  the 
matter  of  the  age  at  which  the  menopause  is  established.  It  has 
been  my  observation  that  the  climacteric  appears  at  about  the  same 
age  in  mother  and  daughter;  that  a  late  or  an  early  menopause 
is  a  common  characteristic  in  the  women  of  certain  families.  My 
personal  experience  as  to  the  average  age  has  to  do  with  an  analysis 
of  the  records  of  eighty-eight  cases  of  women  between  the  ages  of 
forty-one  and  fifty-nine  who  consulted  me  in  Boston  or  New 
England,  for  uterine  disease.  (See  tables,  pp.  604-611).  All  cases 
of  myoma,  cancer  of  the  uterus  which  manifested  itself  previous 
to  several  years  after  the  cessation  of  the  menses,  and,  of  course, 
artificially  induced  menopause,  are  excluded.  The  average  age 
of  the  menopause  in  these  cases  was  46.78  years.  This  may  be 
considered  as  a  fair  average  for  women  with  uterine  disease  ex- 
clusive of  fibroids  and  cancer,  who  live  in  New  England,  although  a 
larger  number  of  cases,  both  of  those  afflicted  with  gynecological 
troubles  and  of  more  nearly  normal  women,  should  be  gathered 
and  analyzed  before  arriving  at  definite  conclusions. 

PREMATURE  MENOPAUSE 

The  cessation  of  the  menses  previous  to  the  normal  average  time 
is  known  as  premature  menopause,  but  as  variations  from  the 
normal  are  so  frequently  seen  it  will  be  convenient  to  consider  as 
cases  of  this  abnormality  those  which  occur  before  the  fortieth 
year.  The  important  point  to  bear  in  mind  in  establishing  the 
diagnosis  is  to  be  sure  that  a  reasonable  time  has  elapsed  since 
the  last  menstrual  period  to  make  its  recurrence  in  the  future 


THE  MENOPAUSE  599 

seem  improbable.  Apprehensive  patients  often  think  the  change 
of  life  is  at  hand  upon  the  occurrence  of  a  transitory  irregularity 
in  the  menses. 

A  direct  cause  for  the  cessation  of  the  menses  early  is  to  be  found 
sometimes  in  (a)  a  sudden  blow  or  fall,  extreme  fright,  anxiety,  or 
grief  acting  through  the  nervous  system;  (6)  serious  constitutional 
diseases,  such  as  cholera,  septicemia,  the  acute  exanthemata,  or 
poisoning  by  alcohol,  phosphorus,  mercury,  arsenic,  or  lead;  (c) 
diseases  affecting  the  uterine  organs  directly,  such  as  excessive 
lactation-atrophy  of  the  uterus,  steaming  of  the  uterine  cavity 
after  the  method  of  Pincus  (see  p.  286),  or  inflammations  and 
tumors  of  the  ovaries.  Other  factors  which  seem  to  stand  hi  a 
causal  relationship  to  an  early  menopause  are  rapidly  succeeding 
pregnancies  beginning  early  in  life,  and  excessive  venery.  Some 
authors  consider  that  the  southern  races  who  mature  relatively 
young  have  the  menopause  correspondingly  early;  but  others  do 
not  agree  to  this  view  and  consider  that  there  is  no  relationship 
between  the  age  at  which  menstruation  begins  and  the  time  of  its 
cessation.  Obesity,  especially  that  form  which  is  rapidly  acquired, 
is  a  cause  of  an  early  menopause  both  in  the  opinion  of  A.  Currier 
(Medical  News,  1888,  p.  173)  and  myself. 

Although  any  of  these  causes  may  result  in  a  permanent  disap- 
pearance of  the  menstrual  flow,  we  are  by  no  means  sure,  as  pointed 
out  by  Bonier  (loc.  cit.},  that  ovulation  is  also  abolished  and  that 
true  cessation  of  the  reproductive  function  has  been  established, 
and  we  may  agree  with  him  in  the  statement  that  many  of  the 
reported  cases  of  premature  menopause  are  to  be  regarded  with 
suspicion  because  the  absence  of  the  menses  for  a  sufficiently  long 
period  of  time  has  not  been  observed  and  because  an  accurate 
gynecological  examination  eliminating  the  common  causes  of 
amenorrhea  has  not  been  made. 

How  causes  in  class  (a)  act  to  produce  amenorrhea  we  do  not 
know.  It  is  probable  that  the  general  constitutional  diseases  act 
directly  on  the  ovaries.  We  know  that  the  exanthemata  cause 
changes  in  the  ovaries,  as  shown  by  Lebedinsky's  examinations  of 
the  ovaries  from  cases  of  scarlet  fever.  (See  Chapter  XVII.,  p.  285.) 
C.  Vinay  ("La  menopause,"  1908)  has  called  attention  to  the 
frequency  with  which  sclerosis  of  the  ovaries  is  found  in  tuberculous 
individuals,  and  Slavjansky,  according  to  Borner,  found  paren- 


600  THE  MENOPAUSE  AND  OLD  AGE 

chymatous  inflammation  of  the  ovary  in  cholera,  recurrent  fever, 
and  septicemia. 

The  destructive  diseases  of  the  ovaries  originating  either  in  those 
organs  or  in  the  neighboring  organs  of  the  pelvis,  may  well  cause 
the  menopause.  The  surprising  fact  is  that  they  so  seldom  do 
cause  it,  for  in  cases  of  large  cystomata  of  both  ovaries  where  at 
operation  no  sound  ovarian  tissue  can  be  discovered  by  macro- 
scopic examination,  the  patients  generally  report  that  menstruation 
has  taken  place  with  more  or  less  regularity  during  the  growth  of 
the  tumors.  We  must  assume  in  such  cases  that  some  function- 
ating ovarian  tissue  has  been  preserved,  even  though  it  can  not  be 
easily  discovered.  We  know  that  in  ovarian  transplantation  from 
one  individual  to  another,  menstruation  and  ovulation  continue 
as  long  as  ovarian  tissue  is  present,  even  though  this  tissue  is  not 
in  its  usual  situation  with  reference  to  the  uterus,  and  it  seldom 
happens  that  destructive  inflammatory  processes  completely 
eliminate  all  of  both  ovaries. 

A  recent  writer  (M.  M.  Stark,  Surg.,  Gynecol.,  and  Obstet.,  Jan., 
1910,  Vol.  X.,  p.  40)  has  collected  from  the  literature  the  following 
fifty-nine  cases  of  premature  menopause,  occurring  between  the 
ages  of  seventeen  and  thirty,  all  reported  by  reliable  authorities. 

Menopause  at   Reporter                                                                           No.  of  Cases 

17  Kisch 1 

18  Stark 1 

19  Frazer,  Stark,  1  each 1 

20  Dalton,  Kisch,  Stark,  1  each 3 

21  Schalit  1,  Boismont  2,  Courty  1,  Stark  1 5 

22  Mayer  2,  Stark  1 3 

23  Krieger,  Walter,  Stark,  1  each 3 

24  Boismont,  Stark,  1  each 2 

25  Mayer 2 

20  Montgomery  1,  Munde  1,  Boismont  1,  Stark  2 5 

27  Tilt,  Guy,  Boismont,  1  each 3 

28  Foster,  Currier,  Guy,  Boismont,  Stark,  Courty,  1  each  .  6 

29  Mayer,  Boismont,  Courty,  Napier,  1  each 4 

30  Mayer  5,  Tilt  10,  Guy  1,  Felty  1,  Napier  1,  Stark  1.  .  .  19 

58. 

The  number  of  cases  occurring  between  thirty  and  forty  years 
of  age  is,  of  course,  the  largest.  Bonier  (loc.  cit.,  p.  39)  gives  the 
following  as  a  genuine  case  of  premature  menopause  of  unknown 
causation:  "Mrs.  H.,  now  thirty-nine  years  old,  menstruated 


THE  MENOPAUSE 


60l 


regularly  after  twelve  years  of  age.  Married-  aft  4birty-<four  and 
aborted  twice  in  the  course  of  two  years.  When  she  was  thirty-six 
her  husband,  who  had  been  seriously  ill  and  for  whom  she  had 
cared  constantly,  died  suddenly.  Her  menses  ceased  on  the  second 
day  of  her  period  and  although  she  saw  slight  traces  of  a  flow 
twice  subsequently  at  intervals  of  four  or  five  months,  there  had 
been  absolutely  no  flow  for  the  past  two  years.  The  only  symptom 
was  mental  depression.  On  local  examination  the  vagina  was 
somewhat  shortened  and  contracted;  the  cervix  thin-  walled,  soft 
and  small,  with  a  tear  (one  of  the  abortions  was  a  rapid  one  at 
six  months),  and  the  uterus  as  a  whole  very  thin-  walled  and  almost 
membranous.  The  ovaries,  of  practically  normal  consistency,  were 
freely  movable  but  small  in  size." 

DELAYED  MENOPAUSE 

The  menopause  may  be  said  to  be  delayed  when  menstruation 
is  continued  beyond  the  fiftieth  year. 

An  important  point  in  diagnosing  this  condition  is  to  distinguish 
between  irregular  hemorrhages  and  menstruation.  In  many  cases 
careful  questioning  of  the  patient  is  necessary  to  bring  out  the 
difference  clearly. 

Are  ovulation  and  fertility  prolonged  with  menstruation?  There 
are  many  cases.  on  record  of  both  menstruation  and  childbearing 
late  in  life,  some  of  them  most  sensational  and  far  too  large  a  pro- 
portion founded  on  hearsay  evidence  rather  than  on  the  personal 
observation  of  the  reporters.  One  of  the  earliest  cases  is  that 
recorded  by  Pliny  the  Elder,  of  Cornelia,  of  the  family  of  Scipio, 
who  at  the  ago  of  sixty  bore  a  son  who  was  named  Volusius  Satur- 
ninus.  Fordyce  Barker  ("The  Age  of  Women  When  the  Capacity 
for  Childboaring  Ceases,"  Phila.  Med.  Times,  1874)  pointed  out 
that  the  eldest  child  of  Cornelia  was  born  in  the  year  163  B.C.  and 
that  Pliny  was  bom  in  the  year  23  A.D.  and  his  "Historia  Natur- 
alis"  was  published  about  the  year  77;  therefore,  at  least  two 
hundred  years  must  have  elapsed  from  the  time  of  this  extraor- 
dinary birth  to  the  time  when  Pliny  wrote.  Pliny  gave  no  docu- 
mentary evidence  and,  as  he  was  something  of  a  romancer  at  best, 
we  may  class  the  case  as  a  tradition  and  not  as  an  observed  fact. 
In  the  same  way,  if  the  cases  in  the  literature  are  examined  carefully 


602  THE  MENOPAUSE  AND  OLD  AGE 

and  the  sources  of  information  sifted,  the  facts  generally  rest  on 
hearsay  evidence.  Take  the  case  of  Ann  Woods  who  is  said  by  Dr. 
Benjamin  Rush  "to  have  given  birth  to  a  child  after  she  was 
sixty  years  old."  In  this  case  the  evidence  of  the  truth  of  the  story 
rests  entirely  upon  the  assertion  of  the  old  woman  herself  who 
claimed  to  be  ninety-six  years  of  age  when  she  called  at  Dr.  Rush's 
home  "to  beg  for  cold  victuals." 

Dr.  Fordyce  Barker  (loc.  cit.)  reports  the  following  authentic 
case  of  late  childbearing:  "May  6,  1852,  I  attended  a  case  of  labor 
in  St.  Mark's  Place,  New  York  City,  in  consultation  with  the  late 
Dr.  Robson,  of  this  city.  The  labor  was  normal  but  tedious  and 
our  patient  was  delivered  of  a  daughter  by  the  aid  of  forceps.  This 
lady  had  been  married  twenty-seven  years  and  this  was  her  first 
pregnancy.  After  the  birth  of  the  child,  the  husband  showed  to 
Dr.  Robson  and  myself  a  family  Bible,  in  which  the  birth  of  his 
wife  was  recorded  as  having  been  May  5,  1801.  July  3,  1853, 
Dr.  Robson  having  died,  I  attended  this  lady  in  her  second  con- 
finement. The  mother  and  both  daughters  (now  married)  are  still 
living." 

John  Davics  (Lond.  Med.  Gazette,  1847,  Vol.  39,  p.  950)  reported 
the  case  of  a  woman  proved  to  be  sixty-three  years  old  by  her 
baptismal  certificate,  who  had  a  child  when  fifty-five  years  old. 
The  child,  a  girl  eight  years  old,  the  youngest  of  eleven  children, 
was  brought  to  see  Dr.  Davies.  The  mother  had  not  menstruated 
since  the  birth  of  her  youngest  child  and  she  thought  that  men- 
struation had  begun  early,  when  she  was  twelve  or  thirteen  years 
old. 

More  remarkable  still  is  a  case;  reported  by  W.  J.  Kennedy 
(Trans.  Edinburgh  Obstet.  Soc.,  1881-82,  Vol.  VII.,  p.  77)  of  regular 
menstruation  and  a  child  born  at  sixty-two,  to  a  thrice-married 
woman,  the  mother  of  twenty-one  children.  The  facts  in  the  case 
are  well  authenticated,  Dr.  Kennedy  having  known  the  woman 
for  ten  years  and  attended  her  in  her  last  labor,  in  November,  1880. 
Her  husband,  when  applying  to  the  parochial  board  for  relief  in  1879, 
stated  that  his  wife  was  then  sixty  years  old.  She  was  born  in 
October,  1818,  and  was  first  married  in  1838,  herhusband  dying  after 
one  child  was  born.  By  her  second  husband  she  had  nine  children, 
twins  once,  and  two  miscarriages,  and  by  her  third  husband  eleven 
children  and  one  miscarriage.  Her  great  fecundity  outlasting  the 


THE  MENOPAUSE  603 

normal  limit  and  the  regularity  of  childbearing  are  attested  by 
the  following  table  of  the  years  when  the  last  pregnancies  oc- 
curred:— 

Year  Age  of  Patient 

1865 47 

1867 49 

1869 51 

1871 53 

1874 56 

1878 60  miscarriage 

1880 62 

Apparently  ovulation  continues  sometimes  after  menstruation 
has  ceased,  as  attested  by  the  following  cases.  Taylor  ("Medical 
Jurisprudence,"  p.  736)  reports  the  following:  "A  woman  at  forty- 
four  had  given  birth  to  nine  children.  Then  the  menses  were 
scanty  at  the  regular  periods  for  two  years.  They  then  ceased 
entirely  for  a  year  and  a  half  and  at  the  end  of  that  time 
she  was  delivered  of  her  tenth  child.  Therefore,  conception 
must  have  taken  place  eight  or  nine  months  after  the  cessation 
of  the  menses." 

R.  G.  Harm  (Journ.  Obstet.  and  Gyn.  of  Brit.  Empire,  1902, 
Vol.  II.,  p.  290)  reports  the  case  of  a  woman  who  in  her  forty-ninth 
year  gave  birth  to  her  thirteenth  child  after  a  period  of  amenorrhea 
of  three  years  following  the  birth  of  the  twelfth  child  at  forty-six. 
That  ovulation  may  take  place  without  menstruation  the  patho- 
logical finding  of  De  Sinet-y  (Progres  medical,  1877,  No.  23,  p.  450) 
goes  to  show.  He  described  the  post-mortem  appearances  in  a 
woman  thirty-eight  years  of  age  who  had  never  menstruated.  The 
uterus  consisted  principally  of  cervix,  as  in  the  fetus,  and  the  uterine 
cavity  measured  one  and  a  half  to  two  inches  in  length.  The 
ovaries  contained  numerous  corpora  lutea. 

I  think  we  may  assume  that  menstruation  as  well  as  ovulation 
occasionally  lasts  as  late  as  sixty  years.  Kisch  (loc.  cit.,  p.  27) 
cites  a  case  of  Brierre  de  Boismont  as  follows: — The  woman  men- 
struated first  at  twelve,  was  married,  had  several  children,  and 
continued  to  menstruate  without  interruption  until  sixty,  after 
which  she  had  an  in-regular  show  for  four  or  five  months.  Raci- 
borski  (idem)  observed  in  the  Salpetriere  one  woman  who  men- 
struated at  fifty-seven,  one  at  fifty-six,  one  at  fifty-three,  and  two 


THE  MENOPAUSE  AND  OLD  AGE 


at  fifty-two.  Tilt  (loc.  cit.,  p.  26)  gives  the  following  list  of  his 
cases  of  over  fifty  years  of  age,  including  fibroids,  cancer,  and  all 
diseases  presumably: — 


Age 


51. 

52. 
53. 
54. 


No.  of  Cases 

27 

.  .16 


50. 


Age 
57  

No.  of  Cases 
2 

58   

4 

59  

1 

GO  

1 

61.. 

.   2 

In  my  own  list  of  cases,  from  which  fibroids  were  excluded,  the 
menopause  occurred  at  over  fifty  years  as  follows: — 


Age 
51.. 

52. . 
53. . 


No.  of  Cases 


54. 
55. 


No.  of  Cases 

2 

.   2 


As  before  stated,  it  has  been  my  observation  that  fibroid  tumors 
cause  a  delay  in  the  menopause.  Often  in  these  cases  irregular 
hemorrhages  take  the  place  of  menstruation  and  a  most  pains- 
taking inquiry  into  the  symptomatology  is  necessary  to  distin- 
guish menstruation  from  hemorrhage. 

LIST     OF     WOMEN     BETWEEN     THE     AGES     OF    41    AND    59    WHO  WERE 
PASSING   THROUGH    OR    HAD   RECENTLY   PASSED    THE    MENOPAUSE. 


c 

-i 

s 

rt 

"S  M 

6 

OJ 

oJ 

«•§ 

!U 

111 

'~z'5l  03 

Leading    symptoms    and 

X 

oj 

< 

£g 

O  C  "t^ 

"y,  5  £ 

•a  M 

c"oz: 

diagnosis. 

0 

fc10* 

^ 

1. 

A.  B. 

43 

Mar. 

6  ch. 

42t 

6  mos. 

Tachycardia,  pruritus  vul- 

youngest 

vac,  ovaries  atrophied. 

8  yrs. 

2. 

J.  B. 

42 

Mar. 

1  ch. 

42 

40 

2  yrs. 

Flowing,  feeling  of  suffo- 

17 yrs. 

cation,     uterine     polyp, 

tubo-ovaritis. 

3. 

S.  B. 

43 

Mar. 

1  ch. 

43 

42 

1  yr. 

Headaches,  lacerated  cer- 

^ 

22  yrs. 

vix   and   perineum,  ret- 

roversion,    uterus    atro- 

phic. 

4. 

R.K.B. 

58 

Mar. 

No.  ch. 

55 

46 

9  yrs. 

Dyspepsia,     tubo-ovarian 

No.  ab. 

abscess,   under  observa- 

tion eleven  years. 

5. 

E..T.C. 

55 

Mar. 

1  ch. 

52 

3  yrs. 

Neurasthenia,    subin  volu- 

tion,   lacerated     cervix, 

uterus  atrophic   1   yr.   2 

mos.  after  dodging. 

THE  MENOPAUSE 
THE   MENOPAUSE. — (Continued.) 


605 


d 
fc 

o> 

a 

& 

Social 
condition. 

^j-O  to 

)i3  C  C 

6  £•£> 

Age  when 
menses 
ceased. 

Age  when 
dodging  be- 
gan. 

Length  of 
dodging 
time. 

Leading    symptoms    and 
diagnosis. 

6. 

N.M.C. 

45 

Mar. 

Ich. 

35 

10  yrs. 

Irritating  leucorrhea,  va- 

13  yrs. 

ginitis,  uterus  normal  in 

size. 

7. 

J.E.C. 

46 

Mar. 

6ch. 

45* 

Eczema  of  knees,  face,  and 

youngest 

wg 

arms,   neurasthenia,   re- 

10 yrs. 

lieved  since  menopause, 

retroversion,      lacerated 

cervix  and  perineum. 

8. 

D.  D. 

42 

Mar. 

6ch. 

41 

lyr. 

Frequency  of  micturition, 

youngest 

lacerated      cervix     and 

7  yrs. 

perineum,  prolapse. 

9. 

A.M.G. 

55 

Mar. 

No.  ch. 

44} 

40 

4*,  yrs. 

Flowing,  retroversion,  ec- 

No. ab. 

zema  of   vulva. 

10. 

M.F.H. 

49 

Mar. 

5  ch. 

48 

3  mos. 

Retroflexion,      subinvolu- 

youngest 

tion  of  vagina. 

8  yrs. 

11. 

M.  H. 

41 

Mar. 

3ch. 

40 

5  mos. 

Headaches,    hot    flashes, 

youngest 

retroversion,      lacerated 

18  yrs. 

cervix. 

12. 

E.G.H. 

50 

Mar. 

2ch. 

48 

46 

2  yrs. 

Indigestion,    rheumatism, 

youngest 

uterus       atrophic,    pro- 

25 yrs. 

lapse. 

13. 

A.  K. 

47 

Mar. 

3  ch. 

46* 

Hot  flashes,  lacerated  cer- 

youngest 

^*vra 

vix       and       perineum, 

23  yrs. 

through  sphincter. 

14. 

L.  L. 

48 

Sing. 

No  ch. 

43 

Pain    in     abdomen    and 

No  ab. 

back,  frequent  micturi- 

tion, retroversion. 

15. 

G.  M. 

44 

Mar. 

1  ch. 

.  •  • 

42 

2  yrs. 

Nervous  invalid  23  years, 

23  yrs. 

tubo-ovaritis      for      23 

years. 

16 

M.C.M. 

46 

Mar. 

Noch. 

45*. 

7  mos. 

Flowing,  retroversion. 

No  ab. 

17. 

D.L.M. 

41 

Sing. 

No  ch. 

.  .  . 

39 

2  yrs. 

Hysteria  for  many  years, 

No  ab. 

appendicitis,         ovaries 

atrophic  at  operation. 

18. 

R.H.B. 

56 

Mar. 

1  ch. 

50 

Leucorrhea,  frequency  of 

27  yrs. 

micturition,      cystocele, 

hemorrhoids. 

19. 

A.  S. 

56 

Mar. 

No  ch. 

51 

43 

8  yrs. 

Dyspareunia  from  erosion 

No  ab. 

of    fourchette,    frequent 

micturition,        atrophic 

uterus. 

20. 

L.  S. 

49 

Mar. 

7  ch. 

... 

48 

2  yrs. 

Hot     flashes,      dizziness, 

youngest 

flowing,     subinvolution, 

15  yrs. 

lacerated  cervix. 

21. 

L.  S. 

51 

Sing. 

Xo  ch. 

50* 

45 

6  yrs. 

Lifelong  neurasthenia,  re- 

Xo ab. 

troversion. 

22. 

M.  W. 

41 

Sing. 

Xo  ch. 

41 

39 

2  yrs. 

Neurasthenia,        atrophic 

Xo  ab. 

uterus. 

23 

M  A  W. 

48 

Mar. 

7  ch. 

46^ 

1*  yrs. 

Sense  of  prolapse,   retro- 

youngest 

version,  lacerated  cervix 

17  yrs. 

and    perineum,    ovaries 

606 


THE  MENOPAUSE  AND  OLD  AGE 
THE   MENOPAUSE. — (Continued.) 


6 

's, 

Name. 

OJ 
M 

<; 

Social 
condition. 

No.  of  chil- 
dren and 
abortions. 

aj  oj    . 

~  OJ-O 

'S  2  * 

sii 
<i 

Ifc 

^JJ  3 

sp 

Length  of 
dodging 
time. 

Leading    symptoms    and 
diagnosis. 

atrophic    at    operation, 

uterus  not. 

24. 

L.  S. 

45 

Mar. 

2ch. 

44 

None 

Excitable,    can't    control 

youngest 

herself,          retroversion, 

10  yrs. 

atrophic      uterus      and 

vagina. 

25. 

K.  M. 

52 

Mar. 

4ch. 

48 

44 

4  yrs. 

Flowing    for    2    years    of 

youngest 

dodging  time,  hot  flash- 

16 yrs. 

es,  stricture  of  urethra. 

26. 

M.  L. 

43 

Mar. 

6  ch. 

43 

Burning  in  vulva,   retro- 

youngest 

flexion,  lacerated  cervix 

6  yrs. 

and  perineum,  caruncle. 

27. 

H.  C. 

51 

Mar. 

Ich. 

51 

46 

5  yrs. 

Asthma,     heart     disease, 

31  yrs. 

subinvolution,  lacerated 

cervix,  uterus  still  large 

11  years  later. 

28. 

N.F.L. 

48 

Mar. 

3ch. 

47 

1  yr. 

Flowing,      subinvolution, 

youngest 

lacerated  cervix. 

18  yrs. 

29. 

W.  H. 

50 

Mar. 

12ch. 

46 

41 

5  yrs. 

Neurasthenia,   retroflexed 

youngest 

senile  uterus,  proctitis. 

7  yrs. 

30. 

E.G. 

46 

Mar. 

No  ch. 

45 

44£ 

6  mos. 

Frequent      and      painful 

No  ab. 

micturition,      urethritis, 

debility. 

31. 

M.E.H. 

57 

Mar. 

2  ch. 

50 

Hot   flashes   since   meno- 

youngest 

pause,    depression,   ure- 

37 yrs. 

thritis. 

32. 

M.  I. 

56 

Mar. 

8ch. 

49 

^one 

Headaches,  dyspnea  with 

youngest 

menopause,     cancer     of 

17  yrs. 

cervix,     flowing     for    6 

weeks,  ovaries  and  tubes 

atrophic  at  operation. 

33. 

J.  S. 

59 

Sing. 

No  ch. 

55 

53  1 

liyra. 

Enlargement  of  abdomen, 

Noab. 

cancer    of    ovary   (large 

cystoma). 

34. 

B.  C. 

45 

Mar. 

8  ch. 

44.1 

43  .V 

1  yr. 

Pregnancy    suspected,  ec- 

youngest 

zema    of    vulva,    subin- 

6 yrs. 

volution,      retroversion. 

35. 

0.  L. 

46 

Mar. 

No  ch. 

43 

3  yrs. 

Flowing,  polypi  in  cervix. 

No  ab. 

36. 

O.A.B. 

46 

Mar. 

3  ch. 

45] 

Hot  flashes,  incontinence 

youngest 

of     urine,     rheumatism, 

24  yrs. 

hemorrhoids,  subinvolu- 

tion. 

37. 

C.  T. 

46 

Mar. 

2  ch. 

45  A 

Flowing  for  two  months, 

youngest 

retroflexion,       lacerated 

12  vrs. 

cervix  and  perineum. 

38. 

M.  R. 

52 

Mar. 

2  ch. 

51 

8  mos. 

Pain  in  thigh,  retroflexion, 

youngest 

polypi,    proctitis,    sciat- 

22 yrs. 

ica. 

39. 

J.G.B. 

59 

Mar. 

3ch. 

50 

Freauent  micturition,  re- 

(  ro  version,    stenosis    of 

canal. 

THE  MENOPAUSE 

THE   MENOPAUSE. — (Continued.) 


607 


6 
fc 

OJ 

eS 
fc 

a5 

M 

< 

Social 
condition. 

No.  of  chil- 
dren and 
abortions. 

Age  when 
menses 
ceased. 

l3«- 

£'3>g 

$* 

Length  of 
dodging 
time. 

Leading    symptoms    and 
diagnosis. 

40 

G.P.P. 

57 

Mar. 

4ch. 

50 

Leucorrhea,       endometri- 

41. 
42. 

43 

C.A.N. 
S.  H. 

E.  S. 

52 
56 

57 

Mar. 
Mar. 

Mar. 

youngest 
27  yrs. 
Ich. 
15  yrs. 
Ich. 
32  yrs. 

3ch. 

48 
54 

51J 
47 

6mos. 
1  yr. 

tis,  cervix  atrophic,  uter- 
ine cavity  3J  inches. 
Indigestion,       headaches, 
tubo-ovaritis,  anemia. 
Leucorrhea  1  year,  pain  in 
groin  1  year,  cancer  of 
cervix,  atrophic  vagina. 
Vaginismus,      headaches 

44 

C  D 

50 

Mar. 

4ch. 

49 

cicatrix  in  perineum,  le- 
sion of  central  nervous 
system. 
Watery  leucorrhea  for  two 

45. 
46 

A.  J. 
E  H. 

50 
49 

Mar. 
Mar. 

youngest 
15  yrs. 
5ch. 
youngest 
12  yrs. 

43 
44 

None 

months,  cancer  of  cervix. 

Endometritis,  uterus  and 
vagina  atrophic,  hemor- 
rhoids, leucorrhea. 
Foul  leucorrhea    for    two 

47 

M.A.S. 

45 

Sing. 

No  ch. 

41 

None 

months,  cancer  of  cervix. 
Cystocele    and    prolapse, 

48 

M.  N. 

51 

Mar. 

No  ab. 
8ch. 

43 

cancer  of  ovary,  breast, 
and  liver  later. 
Painful  lump  in  abdomen 

49. 

50. 
11 

C.  T. 

II.  O. 
M  V.R. 

55 

42 
49 

Sing. 

Mar. 
Mar. 

youngest 
18  yrs. 

No  ch. 
Noab. 

No  ch. 
No  ab. 
2ch. 

52 
43 

52 
40 

3  mos. 
2  yrs. 

for    6    months,    colloid 
carcinoma      of      ovary, 
lacerated          perineum, 
gradual      cessation      of 
menses. 
Pain    in    vulva,    urethral 
caruncle,     senile     atro- 
phic uterus  and  vagina. 
Pain  in  bowels,  tubo-ovar- 
itis, lacerated  cervix. 
Foul    leucorrhea    for    six 

52 

W  P  M. 

52 

Mar. 

youngest 
20  yrs. 
2  ch. 

45 

weeks,  cancer  of  cervix, 
prolapse  12  years  ago. 
Ovarian     cystoma     with 

53. 

14 

C.E.O. 

M.  S. 

49 

44 

Sing. 
Mar. 

youngest 
26  yrs. 
No  ch. 
No  ab. 

6  ch. 

43 

48 

3  mos. 

purulent  contents,  acute 
peritonitis. 
Neurasthenia,       retrover- 
sion,  under  observation 
3  years. 
Incontinence  of  urine,  diz- 

55. 
56. 

E.J.S. 

N.  H. 

51 
43 

Mar. 
Mar. 

youngest 
5?  yrs. 
4  ch. 
youngest 
25  yrs. 
No  ch. 
No  ab. 

50 
43 

49J 
42 

6  mos. 

lyr. 

ziness,     dislocation     of 
urethra  downwards. 
Headaches,  flowing,  retro- 
version,  endometritis. 

Hot    flashes    for    first    6 
months  of  dodging  time, 
subinvolution. 

60S  THE  MENOPAUSE  AND  OLD  AGE 

THE   MENOPAUSE. — (Continued.') 


6 

'<£< 

Name. 

So 
<^ 

•35 
1| 

ttg 
o 

No.  of  chil- 
dren and 
abortions. 

Age  when 
menses 
ceased. 

Age  when 
dodging 
began. 

Length  of 
dodging 
time. 

Leading   symptoms  and 
diagnosis. 

57 

M.  E. 

50 

Mar. 

2  ch. 

45 

Hot   flashes,  rheumatism, 

58. 

S.  M. 

57 

Mar. 

youngest 
*30  yrs. 
7  ch. 

54 

vaginitis,     uterus     atro- 
phic. 
Sense  of  prolapse   subin- 

59. 
GO. 
61. 

J.  P. 
J.A.A. 
C.  B. 

59 
46 

48 

Mar. 
Mar. 
Mar. 

youngest 
17  yrs. 
5  ch. 
youngest 
24  yrs. 

4ch. 
youngest 
20  yrs. 

14  ch. 

50 
4-> 

45 

lyr. 

volution,  vaginitis. 

Flowing    at    menopause, 
headaches    before,    pain 
in    abdomen,    lacerated 
cervix  and  perineum. 
Rheumatism,  procidentia, 
lacerated  cervix  and  per- 
ineum, ovaries  normal  at 
operation. 
Flowing   for  six   months, 

(>2. 

Colored 
M.  B. 

58 

Mar. 

youngest 
17  yrs. 
5  ch. 

53 

cancer    of    cervix,    ad- 
vanced. 
Flowing   for   one   month, 

63. 
64. 

M.  B. 
M.  C. 

49 

58 

Mur. 
Mar. 

youngest 
28  yrs. 
Gch. 
youngest 
18  yrs. 

7ch. 

48 
40 

48 

4  inos. 

multilocular       papillary 
cystoma  of  ovaries. 
Headaches,     retroversion, 
lacerated  cervix  and  per- 
ineum, pyosalpinx,  ova- 
ries normal  at  operation. 
Rheumatism,       rectocele, 

65. 

M.  C. 

45 

Mar. 

youngest 
20  yrs. 
2  ch. 

37 

cystocele,    atrophic    va- 
gina. 
Occasional  hot  flashes,  ure- 

(>6. 

M.  C. 

48 

Mar. 

youngest 
10  yrs. 
5  ch. 

44 

thral  caruncle. 
"Falling  of  womb"  eight 

(>7. 

J.  D. 

52 

Mar. 

youngest 
8  yrs. 
6  ch. 

42 

years,  prolapse. 
Unable  to  control  bowels, 

(>8. 

09. 
70. 

S.  J. 

M.  J. 
B.  L. 

50 

59 

53 

Mar. 

Mar. 
Mar. 

youngest 
20  yrs. 

2  ch. 

1  oh. 
31  yrs. 

10  ch. 

50 

50 
49! 

48! 
43 

2!  yrs. 
7  yrs. 

lacerated            perineum 
through  sphincter,    pol- 
yp, urethral  caruncle. 
Tubo-ovaritis,           uterus 
atrophied    at  operation, 
ovaries    and    tubes   not, 
according  to  pathologist. 
Flowing    during    dodging 
time,  abdominal  tumor, 
lacerated    cervix. 
Painful    micturition,  urc- 

71. 
72. 

C.  L. 
A.  L. 

49 
53 

Mar. 
Sing. 

3  ch. 
youngest 
22',  yrs. 
No  ch. 
No  ab. 

45 

42 
49 

3  yrs. 
4  yrs. 

thritis,  urethral  caruncle. 
Scalding  at  vulva,  eczema 
of  vulva. 

Painful  defecation,    hem- 
orrhoids, partial  atrophy 
of  uterus. 

THE  MENOPAUSE 
THE   MENOPAUSE. — (Continued.) 


609 


0 

fc 

«j 

a 
* 

c 
a 
<i 

Social 
condition. 

No.  of  chil- 
dren and 
abortions. 

Age  when 
menses 
ceased. 

Age  when 
dodging 
began. 

Length  of 
dodging 
time. 

Leading    symptoms    and 
diagnosis. 

73. 

74. 

75 

F.J.M. 

E.M.D. 
M.  M. 

57 

42 
49 

Mar. 

Sing. 
Mar. 

No  ch. 
1  ab. 

No  ch. 
No  ab. 

1  ch. 

48 
44 

47 
42 

lyr. 
3  mos. 

Hot  flashes  and  headaches 
during     dodging     time, 
cystitis,  proctitis,  retro- 
flexion. 
Hysteria,  hot  flashes,  retro- 
version,    adherent    pre- 
puce, masturbation. 
Flowing  for  one  year   ab- 

76. 

77 

A.  F. 
A.  F. 

50 
49 

Sing. 
Mar. 

14yrs. 

No  ch. 
No  ab. 
No  ch. 

47 
4?. 

... 

None 

dominal    cancer,    lacer- 
ated   cervix    and    peri- 
neum. 
Nervous  headaches  since 
menopause,  hemorrhoids. 
Tumor    in    abdomen    for 

78 

E.  F. 

56 

Mar. 

No  ab. 
4ch. 

46 

twelve    years,    dermoid 
ovarian  cystoma. 
Yellow  leucorrhea  for  one 

79. 

80 

S.  G. 
L.  G. 

47 

48 

Sing. 
Mar. 

youngest 
22  yrs. 

No  ch. 
No  ab. 

6ch. 

46 
45 

44 

2  yrs. 

and  a  half  years.  Tuber- 
culosis of  endometrium, 
ovaries  and  tubes  atro- 
phic  at  operation. 
Flowing  two  months,  ma- 
lignant adenoma  of  uter- 
us,   cervix    and    vagina 
atrophic. 
Flowing,  polyp,  subinvo- 

81. 
82. 

F.  H. 
M.  H. 

46 
53 

Mar. 
Mar 

youngest 
14  yrs. 

6ch. 
10  ch. 

44J 
52 

None 

lution,  lacerated    cervix 
and    perineum,    cardiac 
disease. 
Flowing  for  six  months, 
uterine  polyp. 
Pain   in  pelvis,  dizziness, 

83 

H.  J. 

45 

Sing. 

No  ch. 

45 

urethritis,     cystitis,  va- 
ginitis. 
Flowing,    fungous    endo- 

84. 

85 

J.  M. 
M.  M 

49 

52 

Mar. 
Mar. 

No  ab. 
No  ch. 
1  ab. 

1  ch. 

42 

47 

2  yrs. 

metritis. 
Flowing    for    two    years, 
hyperplastic  endometri- 
tis. 
Painful  and  bloody  mictu- 

86 

M  M 

42 

Mar 

25  yrs. 
2  ch. 

40 

rition,  stone  in  bladder, 
prolapse. 
Frequent  micturition  and 

87 

J.P.M. 

52 

Mar. 

youngest 
*  6  yrs. 

Xo  ch. 

50 

bearing     down,    polyp, 
lacerated      cervix      and 
perineum. 
Flowing  for  two  years,  ad- 

88 

M.  M 

55 

Mar. 

Xo  ab. 
9  ch. 

49A 

eno-carcinoma  of  cervix. 
Sense    of    prolapse,    pro- 

89 

D.  O 

52 

Mar. 

12  ch. 

44 

lapse. 
Xo  symptoms    at    meno- 

youngest 
19  yrs. 

pause,    retroversion,  tu- 
mor of  pelvis. 

39 


610 


THE  MENOPAUSE  AND  OLD  AGE 
THE    MENOPAUSE. — (Continued.} 


6 
ft 

Name. 

3 

<; 

Social 
condition. 

No.  of  chil- 
dren and 
abortions. 

c 
111 

||| 

5  M    . 

*|8 

5c|^ 
<-" 

"3  M 

xs.a« 

w*S 

So~ 

•3-° 

Leading   symptoms  and 
diagnosis. 

90. 

M.L.P. 

00 

Mar. 

No  ch. 

50 

48 

2  yrs. 

Indigestion,  frequency  of 

No  ab. 

micturition,         atrophic 

uterus. 

91. 

M.  P. 

58 

Mar. 

2ch. 

50 

49 

lyr. 

Incontinence  of  urine,  tu- 

mor     of      vagina      six 

months,  malignant  ade- 

noma of  vagina. 

92. 

A.  R. 

49 

Mar. 

6  ch. 

44 

Painful  micturition  lacer- 

ated   cervix    and    peri- 

neum, uterus  atrophic  at 

ether  examination. 

93. 

II.  D. 

50 

Mar. 

7  ch. 

48 

Flowing  for  one  and  a  half 

6ab. 

' 

years,        subinvolution, 

endometritis. 

94. 

.1.  G.  S. 

52 

Mar. 

1  ch. 

50 

48 

2  yrs. 

Hot  flashes  for  four  or  five 

20  yrs. 

years,      lacerated     peri- 

neum, intestinal  catarrh. 

95. 

L.  S. 

45 

Mar. 

2ch. 

44 

None 

Hot     flashes,     urethritis, 

youngest 

dislocation     of    urethra 

10  vrs. 

downward. 

96. 

L.  S. 

48 

Mar. 

7ch. 

47 

lyr. 

Dizziness,  pain  in  left  side, 

youngest 

subinvolution,  lacerated 

15  yrs. 

cervix,  endometritis. 

97. 

F.L.S. 

49 

Mar. 

3ch. 

48 

lyr. 

Frequent  micturition,  sub- 

youngest 

involution,       urethritis, 

1  6  yrs. 

cystitis. 

98. 

E.  S. 

47 

Mar. 

Ich. 

45 

2  yrs. 

Flowing,      subinvolution, 

27  yrs. 

polyp. 

99. 

J.  AV. 

46 

Sing. 

No  ch. 

441  Hyrs. 

Leucorrhea,  headaches,  re- 

No ab. 

tro  version,  vaginitis,  old 

pelvic  inflammation. 

100. 

L.  R. 

52 

Mar. 

3  ch. 

50 

Flowing  for  three  weeks, 

youngest 

lacerated  cervix  and  per- 

15 yrs. 

ineum,  polyp,  fistula  in 

ano. 

101 

M  E  L 

52 

Alar 

3  ch. 

51 

Prolapse   lacerated  cervix 

and  perineum. 

102. 

B.  C. 

56 

Mar. 

1  ch. 

51 

Flowing   for  six   months 

20  vrs. 

cancer  of  body  of  uterus. 

103. 

M.  C. 

50 

Mar. 

9  ch. 

49 

8  mos. 

Sense   of   prolapse,   lacer- 

youngest 

ated  cervix  and  perine- 

* 10  yrs. 

um,  procidentia. 

104. 

M.  D. 

48 

Sing. 

No  ch. 

47 

lyr. 

Flowing     for     one    year, 

No  ab. 

polyp. 

10.5. 

A.  C. 

49 

Mar. 

8  ch. 

48 

Sense     of    prolapse      lac- 

erated  cervix  and  peri- 

neum, prolapse. 

106. 

M.  D. 

54 

Mar. 

3ch. 

48 

Can't  control  bowels,  lac- 

erated  cervix  and  peri- 

neum through  sphincter. 

107. 

J.  M. 

52 

Mar. 

10  ch. 

50.1 

Prolapse,  lacerated  cervix 

youngest 

and  perineum. 

7  yrs. 

THE  MENOPAUSE 

THE    MENOPAUSE. — (Continued.) 


611 


6 

£ 

Name. 

<B 
t* 
< 

Social 
condition. 

No.  of  chil- 
dren and 
abortions. 

Age  when 
menses 
ceased. 

£  M 

~  5  c' 
£'Sg 

|H 

*0  M 

•e.Sa> 

3£J: 
s  o*» 

•3"° 

Leading    symptoms    and 
diagnosis. 

108. 

L.  D. 

46 

Sing. 

1  ch. 

44 

Prolapse,    lacerated    cer- 

109. 

B.  B. 

54 

Mar. 

12  yrs. 
2ch. 

44 

vix  and  perineum,  uter- 
us and  ovaries  atrophic. 
Leucorrhea  and  sense  of 

110. 

M.  D. 

52 

Mar. 

No  ch. 

48 

prolapse,  cystocele   and 
rectocele. 
Flowing   two   and  a  half 

111. 
112. 

C.  N. 
A.  H. 

54 

48 

Mar. 

Sing. 

lab. 
7ch. 
No  ch. 

47 
45 

... 

^one 

years,  uterus  large,  spin- 
dle-celled    sarcoma     of 
ovary. 
Painful  and  bloody  mictu- 
rition two  months,  can- 
cer of  bladder. 
Flowing  for  six  months 

113. 

M.E.T. 

56 

Mar. 

No  ab. 
2  ch. 

50 

cancer  of  body  of  uterus. 
No  complaint  except  pro- 

114. 

M.  M. 

57 

Sing. 

youngest 
32  yrs. 
No  ch. 

51 

lapse,     lacerated     peri- 
neum. 
Acute  obstruction  of  bow- 

115. 

B.  D. 

54 

Mar. 

No  ab. 

44 

els,  cancer  of  sigmoid. 
Pain  in  abdomen,  cysto- 

ma  of  left  ovary,  right 
ovary  atrophic  at  oper- 
ation. 

THE  DODGING  TIME 

Tilt  and  others  have  called  the  time  from  the  beginning  of  ir- 
regularity of  the  menses  to  their  cessation,  the  dodging  time.  In 
his  500  tabulated  cases  there  was  no  dodging  time  hi  137  women, 
menstruation  stopping  suddenly  in  these.  The  average  length  of 
the  dodging  time  in  265  cases  was  2.2  years.  In  my  own  list,  data 
as  to  the  length  of  the  dodging  time  were  obtained  in  62  cases. 
Of  these  8  had  no  dodging  time  and  of  the  54  remaining  the 
average  time  was  2.2  years.  However,  of  these  the  dodging  time 
was  surely  completed  in  only  23  and  in  these  the  average  was  2.8 
years,  the  longest  10  years,  and  the  shortest  3  months. 

I  think  we  should  agree  with  Tilt  that  very  little  can  be  deduced 
as  to  the  normal  dodging  time  from  these  figures.  Sudden  cessation 
of  the  menses  is  of  comparatively  infrequent  occurrence.  In  many 
of  the  women  there  was  noted  an  alteration  in  either  or  both  the 
quantity  and  the  quality  of  the  menstrual  blood,  also  certain 


612  THE  MENOPAUSE  AND  OLD  AGE 

phenomena  such  as  hot  flashes  and  nervous  instability,  previous 
to  the  beginning  of  irregularity  of  rhythm,  so  that  the  inference  is 
justified  that  ovarian  influence  begins  to  fail  before  menstruation 
becomes  irregular. 

Two  years  and  nine  and  a  half  months  (2.8  years)  represents  the 
average  duration  of  the  dodging  time  as  influenced  by  uterine  or 
ovarian  disease  in  my  series  of  cases ;  hardly  enough  cases  to  warrant 
any  weighty  conclusions,  however.  We  know  nothing  about  the 
factors  that  govern  a  sudden  or  a  prolonged  menopause,  and  we 
have  no  means  of  knowing  in  any  given  case  what  the  issue  is  likely 
to  be. 

We  speak  of  the  menopause  being  over,  or  passed,  when  the 
genital  hemorrhages  have  ceased.  Of  course,  this  is  not  necessarily 
the  case,  for  the  changes  in  both  the  body  (the  uterine  organs  and 
the  system  at  large)  and  in  the  psychical  state  of  the  individual 
that  are  peculiar  to  the  menopause  may  be  only  begun  when  the 
menses  cease.  On  the  other  hand,  these  general  phenomena  may 
precede  the  disappearance  of  the  menses;  therefore  we  might, 
perhaps,  mark  the  beginning  and  the  end  of  the  climacteric  by  the 
appearance  and  the  cessation  of  these  phenomena,  rather  than  by 
the  stopping  of  menstruation. 

PHENOMENA   OF  THE   MENOPAUSE   IN   BODY  AND   MIND 

Leaving  for  consideration  in  the  succeeding  section  the  influence 
of  diseased  uterine  organs  on  the  menopause,  let  us  examine  here 
the  manifestations  of  the  change  of  life  in  the  other  portions  of  the 
body. 

Cardio- vascular  System. — Hot  Flashes. — Hot  flashes,  or  flushes, 
are  probably  the  most  frequent  and  the  most  annoying  of  the 
symptoms  of  the  menopause.  In  a  well-developed  hot  flash  the 
patient  at  first  feels  hot,  some  portion  of  the  skin  of  the  body, 
generally  the  face  and  hands,  being  suddenly  filled  with  blood; 
a  sort  of  exaggerated  blush.  Immediately  afterward  sweating 
occurs  and  finally  the  patient  feels  cold,  the  chilly  sensation  coming 
on  either  while  the  sweating  is  in  progress  or  after  it  has  ceased. 
The  vigor  with  which  these  flashes  seize  the  individual  vary  greatly 
in  different  patients  and  in  the  same  patient  at  different  times. 
Also  the  frequency  of  their  recurrence  varies  from  as  many  as  ten 


THE  MENOPAUSE  613 

an  hour  in  one  case  of  artificial  menopause,  reported  by  Bland- 
Sutton  ("Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes," 
p.  486)  to  an  occasional  irregular  flash.  No  two  cases  are  alike  and 
there  seems  to  be  no  definite  relation  between  the  sudden  occurrence 
of  the  menopause  and  the  severity  or  frequency  of  the  flashes,  except 
that  in  the  case  of  the  artificial  menopause  the  flashes  are  generally 
more  severe.  Ordinarily  the  flashes  are  most  severe  in  the  beginning 
when  the  menses  first  become  irregular  and  gradually,  as  the  months 
go  by,  are  less  and  less  pronounced. 

Tachycardia  and  High  Arterial  Tension. — Paroxysmal  increase 
in  the  rapidity  of  the  heart's  action  and  a  general  high  arterial 
tension  have  been  observed  in  women  at  the  menopause.  These 
disturbances  are,  as  in  the  case  of  the  hot  flashes,  due  to  derange- 
ment of  the  vaso-motor  nervous  mechanism.  They  may  be  due  to 
preexisting  heart  disease,  but  occur  in  women  who  have  no  dis- 
coverable heart  lesion.  Stokes  first  called  attention  to  them  and 
they  have  been  studied  more  recently  by  Kisch  (Berlin,  klin. 
Woch.,  1889),  Fiessinger  (Journ.  des  Praticiens,  1902,  p.  802), 
Pawinski  ("Tension  arterielle  dans  la  menopause,"  Acad.  Med., 
1904),  and  L.  Williams  (Clin.  Journ.,  March  3, 1909,  Vol.  XXXIII., 
p.  329).  If  we  assume  that  a  manometric  reading  of  the  pulse 
just  before  a  normal  menstrual  period  of  130  to  150  millimeters 
of  mercury  represents  the  highest  average  during  sexual  life  (the 
lowest  being  about  110  millimeters  just  after  a  menstrual  period) 
the  manometer  may  show  a  blood  pressure  of  180  millimeters  in 
the  pulse  of  a  woman  who  is  passing  through  the  menopause.  The 
pulse  feels  bounding  and  full.  The  patient  complains  of  palpita- 
tion, which  is  often  especially  annoying  at  night  and  is  accompanied 
by  smothering  sensations.  Sometimes  in  marked  cases  there  is 
active  dyspnea,  the  respiration  becoming  embarrassed  at  the  least 
effort.  The  pulse  rate  may  be  as  high  as  150  or  160  a  minute  and 
sometimes  it  is  also  irregular,  even  in  cases  where  organic  heart 
disease  can  be  absolutely  excluded. 

The  Nervous  System. — The  phenomena  of  derangement  of  function 
of  the  vascular  system  that  have  been  described  already  are  un- 
doubtedly caused  by  some  unknown  impairment  of  the  nervous 
mechanism.  Other  indications  of  functional  nervous  disease  are 
intercostal  neuralgia,  insomnia,  ringing  in  the  ears,  loss  of  memory, 
suspicions,  and  change  in  character,  especially  by  developing  irri- 


614  THE  MENOPAUSE  AND  OLD  AGE 

lability  of  temper.  The  small  every-day  annoyances  assume  ex- 
aggerated importance  and  become  insupportable.  Many  women 
from  being  of  a  cheerful  disposition  become  habitually  sad  and 
depressed.  The  thought  is  forced  upon  us  that  this  state  of  mind 
is  in  part  due  to  the  gloomy  views  about  the  change  of  life  that 
have;  been  held  by  both  laity  and  the  profession  in  the  past.  To 
some  women  we  can  imagine  that  the  knowledge  that  the  child- 
bearing  function  is  going,  that  she  is  becoming  unsexed,  is  a  dispirit- 
ing thought.  If  in  addition  sexual  pleasures  have  been  an  important 
feature  of  her  life  the  disappearance  of  these  may  be  an  added 
source  of  melancholy.  Vinay  (loc.  cit.,  p.  107)  thinks  that  such  a 
thought  caused  Mine,  du  Deffant  to  remark  with  regret,  "Formerly, 
when  I  was  a  woman." 

Neurasthenia  is  a  common  accompaniment  of  the  menopause 
but,  more  often  than  not,  does  not  originate  at  that  time.  Many 
nervous  stigmata  long  existent,  perhaps  inherited  but  not  noticed 
by  either  the  patient  or  her  physician,  come  to  the  fore  at  the 
change  of  life.  Hysteria  is  developed  sometimes  at  the  menopause, 
but  here  in  a  majority  of  cases  a  careful  sifting  of  the  history  will 
detect  stigmata  as  having  been  present  in  the  past. 

Sexual  Feeling  at  the  Menopause. — This  subject  has  been  studied 
by  Brierre  de  Boismont,  Gueneau  de  Mussy,  and  other  French  writers. 
It  would  appear  that  there  exists  in  many  women  an  excess  of  sexual 
passion  at  the  close  of  the  menstrual  life  in  not  only  the  married 
but  in  widows  and  the  unmarried.  This  is  shown  by  platonic 
affections,  by  a  morbid  attraction  for  the  opposite  sex,  young  boys 
even  being  selected  as  the  objects  of  lavish  attentions,  or  by  mas- 
turbation, nymphomania,  or  excessive  lustfulness.  Venereal 
desires  become  a  positive  obsession  in  some  women  and  they  may 
affect  those  who  have  not  experienced  them  previously  during 
their  lives.  Sexual  feelings  are  apt  to  be  manifest  at  the  times 
when  menstruation  should  occur  and  the  seizures,  which  are  of 
short  duration,  but  perhaps  often  repeated,  seem  to  replace  the 
periods.  They  are  accompanied  often  by  hypochondria  and  melan- 
choly. At  the  conclusion  of  the  menopause  sexual  feeling  gen- 
erally disappears,  though  it  may  not.  11.  G.  Hann  (Journ.  Obstet. 
and  Gyn.  of  British  Empire,  1902,  Vol.  II.,  p.  290)  reports  the 
unusual  case  of  a  woman,  the  mother  of  twelve  children,  who 
ceased  to  menstruate  at  fortv-six  vears.  Then  all  sexual  feeling 


THE  MENOPAUSE  615 

was  lost.    Three  years  later  she  gave  birth  to  her  thirteenth  child 
and  sexual  feeling  returned  with  the  first  menstrual  period. 

Mental  Diseases. — Many  diseases  of  the  nervous  system  are 
separated  by  such  a  delicate  line  from  the  diseases  of  the  mind 
that  their  differentiation  is  often  a  matter  of  great  difficulty.  In 
the  first  place  it  may  be  best  to  state  that  there  is  no  such  thing  as 
climacteric  insanity  in  the  opinion  of  such  an  authority  on  insanity 
as  M.  Craig,  of  the  West  Riding  Asylum  in  England.  Of  the  two 
hundred  and  twenty-two  cases  of  insanity  during  the  menopause 
occurring  in  the  West  Riding  and  Bethlehem  asylums  in  ten  years, 
(Journ.  of  Mental  Science,  1894,  Vol.  XL.,  p.  236)  between  63.3 
and  68.6  per  cent,  respectively,  were  cases  of  melancholia.  H. 
Berger,  of  Jena  (Monatss.  fur  Psychiatric  u.  Neurol.,  1907,  Bd. 
XXII.,  Erganz.  Heft  13),  reports  a  similar  conclusion  from  a  series 
of  fourteen  cases  which  he  has  studied  and  a  review  of  the  literature, 
and  this  corresponds  with  the  experience  of  most  writers  on  mental 
disease  that  melancholia  is  most  often  observed  at  this  time  of 
life.  The  other  diseases  with  their  respective  percentages  observed 
by  Craig  were  as  follows: — 

Mania,  15-18;  Weak-mindedness,  2-1; 

Delusional  insanity,  9-14;  General  paralysis,  2-1. 

He  attributes  an  important  influence  to  heredity  in  the  causation 
of  mental  disease  at  this  time,  and  points  out  that  the  menopause 
has  a  deleterious  effect  on  preexisting  psychoses;  therefore,  from 
this  point  of  view,  we  are  justified  in  classing  the  menopause  as  a 
critical  time  of  life.  We  must  remember,  however,  that  the  patients 
who  happen  to  be  in  the  insane  asylums  during  the  climacteric 
years,  are  only  a  small  proportion  of  all  women  of  that  age  in  the 
community,  and  that  the  causative  agency  of  the  menopause  in 
producing  mental  disease  is  still  most  indefinite. 

The  Alimentary  Canal. — Eisner  found  in  the  stomachs  of  men- 
struating women  hyperchlorhydria  that  he  attributed  to  hyperemia 
of  the  gastric  mucous  membrane  coincident  with  the  hyperemia  of 
the  uterine  mucosa.  At  the  menopause  there  is  often  found  an 
atonic  gastritis  with  hyperchlorhydria.  Dyspepsia  of  one  kind  or 
another  is  frequently  observed  at  the  menopause,  especially  among 
American  women  where  dyspepsia  is  such  a  common  disease  at  all 
ages.  Patients  suffer  with  epigastric  pain  and  heartburn  two  or 


616  THE  MENOPAUSE  AND  OLD  AGE 

three  hours  after  eating.  There  are  acid  eructations  and  some- 
times vomiting  and  constipation.  Gallard,  according  to  Vinay, 
called  attention  to  the  penchant  that  many  women  have  during  the 
menopause  for  strong  liquors  and  assigned  part  of  the  dyspepsia 
to  an  alcoholic  habit.  Chronic  gastro-enteritis  may  be  the  cause 
of  obstinate  constipation  which  is  common  at  the  menopause. 
Puech  found  hematemesis  as  a  vicarious  menstruation  in  some 
of  his  women,  but  other  authors  do  not  mention  it. 

The  Nutrition. — Obesity  appears  in  certain  young  girls  of  a 
lymphatic  type  as  they  reach  puberty.  It  is  also  often  observed  in 
women  after  prolonged  lactation,  and  it  is  a  very  frequent  con- 
comitant of  the  menopause,  either  normal  or  artificial.  The  same 
increase  in  fat  is  seen  in  capons,  oxen,  and  other  castrated  animals. 
Most  of  the  fat  is  deposited  in  the  panniculus  adiposus  of  the 
anterior  abdominal  wall,  over  the  breasts,  the  buttocks  and  the 
hips,  and  less  in  the  limbs  and  face.  The  abdomen  gets  larger  at  the 
menopause  both  because  of  the  excessive  accumulation  of  adipose 
tissue  in  the  anterior  abdominal  wall,  and  also  because  of  the 
deposit  of  fat  in  the  mesentery  of  the  intestine  and  in  the  omentum, 
perhaps  accompanying  gastro-intestinal  disturbances  with  chronic 
flatus.  The  increase  in  body  size  due  to  obesity  at  the  menopause 
is  seldom  excessive. 

Where  loss  of  flesh  accompanies  the  menopause,  as  it  occasionally 
docs,  we  look  for  some  definite  fault  of  nutrition.  Anemia  occurs  at 
the  climacteric  especially  in  those  women  who  have  lost  much  blood 
as  a  result  of  uterine  hemorrhages.  There  are  pallor  of  the  face  and 
lips,  shortness  of  breath  on  the  slightest  effort,  indigestion,  hemic 
murmurs  over  the  precordia,  and  headaches  and  nervous  irritability. 

Rheumatism.— F.  Neumann  (Med.  Kim.,  Berlin,  1908,  Vol.  IV., 
p.  407),  physician  to  the  baths  of  Baden-Baden  where  3, 158  women 
with  joint  disease  (acute  and  chronic  rheumatism  of  the  joints, 
arthritis  deformans,  and  gout)  were  treated  in  the  seven  years  from 
1901  to  1907,  inclusive,  notes  the  frequency  of  the  association  of 
chronic  joint  disease  with  the  menopause.  He  has  found  that  many 
women  with  chronic  joint  disease  date  the  beginning  of  their  ailment 
from  the  climacteric  or  the  time  just  after  it.  He  had  seen  forty- 
seven  cases  of  this  relation  in  the  previous  two  years  and  a  case 
where  joint  affections  had  been  associated  with  the  menopause 
artificially  induced  by  castration.  Whether  the  occurrence  of 


THE  MENOPAUSE  617 

rheumatism  at  this  time  has  to  do  with  deficient  elimination  of 
waste  products  because  of  changes  in  the  excretory  glands  of  the 
body  at  the  menopause,  as  assumed  by  many  writers,  is  still  sub 
judice.  The  urinary  function  seems  to  be  impaired  and  deficient 
elimination  with  lithiasis  occurs  in  some  cases. 

The  Skin. — Pruritus  and  eczema  are  most  common  at  the  meno- 
pause and  are  frequently  localized  in  the  region  of  the  vulva  or  anus. 
Urticaria  and  acne  rosacea  are  not  infrequently  seen.  Growth  of 
hair,  especially  on  the  chin,  the  upper  lip,  and  about  the  breasts,  is 
sometimes  observed  at  this  time. 

The  diseases  of  the  breasts  have  been  considered  in  Chapter 
XXVII,  page  531. 

INFLUENCE  OF  UTERINE  DISEASES  ON  THE  MENOPAUSE 

A  certain  relatively  few  uterine  diseases  originate  at  the  meno- 
pause, such  as  injuries  to  an  atrophic  vagina  from  coitus,  pruritus 
vulvse,  and  prolapse.  A  large  majority,  however,  have  their  origin 
long  before  the  menses  begin  to  be  irregular,  even  though  they  may 
have  previously  excited  little  attention  from  either  the  patient  or 
the  physician. 

Hemorrhages. — Let  us  consider  first  the  pathological  conditions 
which  give  rise  to  hemorrhages  at  the  menopause. 

(a)  Fibroids. — The  most  frequent  of  these  are  fibroids  of  the 
uterus  in  situation  either  submucous  or  interstitial.  The  bleeding 
in  such  cases  is  apt  to  begin  as  menorrhagia  occurring  after  the 
thirty-fifth  year,  gradually  becoming  greater  in  amount,  and  finally 
resulting  in  metrorrhagia  as  the  patient  enters  the  forties.  Ab- 
dominal or  pelvic  pain  may  accompany  the  flow;  it  may  be  in- 
dependent of  it  or  it  may  be  absent.  Expulsive,  labor-like  pains 
are  present  sometimes  when  a  submucous  nodule  is  being  driven 
out  of  the  uterus.  More  often  the  uterus  becomes  atonic  from  the 
prolonged  presence  of  the  foreign  body  and  the  patient  experiences 
no  pain.  The  subject  of  fibroid  tumors  is  described  at  length  in 
Chapter  XV.,  page  244.  It  is  enough  here  to  counsel  a  thorough 
local  examination  in  the  case  of  every  woman  who  has  excessive 
flowing  at  or  about  the  menopause.  We  know  that,  although  some 
fibroid  tumors  diminish  in  size  and  cause  no  symptoms  after  the 


618  THE  MENOPAUSE  AND  OLD  AGE 

menopause  has  been  established,  the  majority  do  not  atrophy,  and 
even  if  they  do  they  are  subject  to  a  variety  of  degenerative  changes 
that  jeopardize'  the  health  or  even  the  life  of  the  patient.  Not  only 
that,  but  the  change;  of  life  is  delayed  in  the  possessors  of  fibroid 
uteri  and  the  loss  of  strength  from  prolonged  and  repeated  hemor- 
rhage, with  its  consequent  anemia,  constitutes  a  handicap  from 
which  many  untreated  women  never  recover.  Others,  hardier, 
the  more  rapid  blood-makers,  survive  the  drain  on  their  vitality 
and  are  able;  to  get  back  into  good  condition  after  a  series  of  years 
of  invalidism,  and  still  others,  the  very  tough  sort  who  can  stand 
anything,  are  not  seriously  incommoded. 

(6)  Suhinwlution.—The  next  most  frequent  cause  of  hemorrhages 
at  the  climacteric  is  the  condition  known  variously  as  subinvolution 
or  chronic  metritis,  with  or  without  lacerated  cervix.  In  looking  over 
my  list  of  cases  of  women  who  were  either  passing  through  or  had 
passed  the  menopause  (see  pages  604-611)  I  find  the  diagnosis  of 
subinvolution  or  badly  lacerated  cervix  noted  in  thirty-five  of  the 
ninety  parous  women  in  the  list.  Not  all  of  these  suffered  with 
flowing,  but  it  is  plain  that  if  the  uterine  muscle  has  been  replaced 
by  connective  tissue  or  elastic  tissue  and  has  acquired  an  increased 
bulk  because;  of  these  changes  in  its  tissues  brought  about  by 
chronic  engorgement,  the  retrograde  alterations  in  its  structure 
which  normally  take  place  at  the  menopause  are  hindered,  so  that 
the  organ  can  not  shrink  to  the  diminutive  size  found  in  old  age 
under  non-pathological  conditions,  except  after  a  longer  time  and 
at  the  expense  of  disquieting  local  symptoms  in  the  form  of  hemor- 
rhages and  leucorrhea,  and  general  symptoms  as  described  in  the 
last  section. 

(f)  Endometntis.—Endometritis  occurring  under  the  varieties 
of  fungous,  polypoid,  and  glandular,  is  a  cause  of  both  flowing  and 
leucorrhea  at  the  menopause  in  a  considerable  number  of  cases. 

(d)  Polypi  were  found  in  ten  of  the  cases  in  my  list  and  other 
observers  have  found  these  frequently  during  the  menopause, 
someauthors  in  the  past  alleging  that  they  were  due  to  thechangeof 
life.  Endometritis  so  often  accompanies  subinvolution  that  in  an 
analysis  one  can  not  separate  the  two.  We  must  regard  the  disease 
as  originating  in  some  infection  long  before  the  menopause,  but  as 
becoming  the  cause  of  hemorrhage  and  leucorrhea  at  that  time 
because;  of  the  altered  rhythm  of  the  pelvic  circulation.  On  account 


THE  MENOPAUSE  619 

of  the  decreased  vitality  of  the  uterine  organs  at  the  menopause 
the  opportunities  for  the  entrance  of  infection  into  the  tissues  are 
enhanced ;  therefore,  it  may  well  be  the  case  that  infections  origi- 
nate at  this  time  in  the  uterine  endometrium  as  they  do  in  the 
vagina.  My  observation  leads  me  to  think  that  in  most  instances  of 
endometritis  at  the  menopause  the  disease  is  an  exaggerated  stage 
of  a  preexisting  endometritis. 

(e)  Cancer  of  the  Uterus. — In  looking  up  my  cases  of  women  who 
were  passing  through  the  menopause  I  found  hi  addition  to  those 
in  the  list  four  who  had  flowing  because  of  cancer, — two  each  of 
cancer  of  the  cervix  and  of  cancer  of  the  body.  There  is  no  evidence 
to  prove  that  the  occurrence  of  cancer,  except  in  the  late  stages  of 
the  disease,  has  any  more  effect  on  the  menopause  than  subin- 
volution.  As  previously  stated,  cancer  is  a  disease  of  the  atrophic 
tissues.  In  my  list  of  one  hundred  and  fifteen  cases  there  are 
seven  cases  of  cancer  of  the  cervix  and  three  of  cancer  of  the 
body  of  the  uterus,  all  ten  presenting  no  symptoms  until  the 
menopause  had  been  well  established  for  ten  months  in  the  short- 
est time,  and  eight  years  in  the  longest.  Thus  we  have  ten  cases 
of  cancer  of  the  uterus  first  manifesting  its  presence  after  the 
menopause  was  over,  as  contrasted  with  four  cases  diagnosed  in 
women  of  the  same  ages, — forty-one  to  fifty-nine, — during  the 
menopause. 

Before  leaving  the  subject  of  hemorrhage  at  the  menopause  it 
may  be  proper  to  state  that  there  are  cases,  although  they  are 
rare,  in  which  no  adequate  explanation  of  flowing  at  the  climacteric 
can  be  found  either  in  the  uterine  organs  or  hi  the  system  at  large. 
There  is  a  probability,  as  suggested  by  Scanzoni  long  ago,  that 
arteriosclerosis  at  this  time  of  life,  by  rendering  the  blood-vessels 
of  the  uterus  more  rigid  and  friable  so  that  they  can  not  withstand 
increased  blood  pressure,  predisposes  to  hemorrhage.  Borner 
(loc.  cit.,  p.  42)  reports  the  following  case  of  unexplained  climac- 
teric flowing:  "Mrs.  R.,  aged  sixty,  had  always  menstruated 
regularly  but  profusely.  She  married  at  twenty-three  and  had 
three  normal  labors  within  seven  years.  She  had  always  enjoyed 
good  health  except  that  she  had  a  highly  irritable  nervous  system. 
At  forty-nine  she  suffered  with  a  sudden  and  profuse  flowing. 
Repeated  loeal  examinations  failed  to  find  any  abnormality  of  the 
uterine  organs  and  a  general  physical  examination  detected  nothing 


620  THE  MENOPAUSE  AND  OLD  AGE 

wrong  with  the  circulatory  system.  Repeated  hemorrhages  at 
longer  or  shorter  intervals  produced  such  profound  anemia  that 
she  was  obliged  to  pass  two  entire  winters  in  bed.  Then,  at  fifty-one, 
the  hemorrhages  ceased  and  she  became  strong  and  well  as  before. 
Another  examination  of  the  uterine  organs  at  this  time  failed  to 
reveal  any  abnormality." 

Displacements  of  the  Uterus  at  the  Menopause. — Displacements 
of  the  uterus  at  the  menopause  except  prolapse  are  of  minor  impor- 
tance. Ret  reversion  is  a  condition  of  the  uterus  that  may  be  regarded 
as  normal  after  the  climacteric  atrophy  has  taken  place.  Prolapse  : 
A  uterus  made  heavy  by  subinvolution  is  more  ap.t  to  sag  down  and 
to  become  prolapsed  at  the  menopause  than  before  because  of  the 
weakening  of  the  uterine  ligaments  and  the  disappearance  of  the 
muscular  wall  of  the  vagina,  coupled  with  a  shortening  and  change 
in  shape  of  the  vagina  at  this  time.  The  cervix  becoming  smaller  and 
the  upper  vagina  assuming  a  narrowed  caliber  and  a  conical  shape, 
the  cervix  no  longer  enters  the  latter  organ  with  its  long  axis  at  a 
right  angle  to  the  long  axis  of  the  vagina,  but  is  a  button  at  the 
upper  end  of  the  shortened,  flabby-walled  vagina. 

Although  only  twelve  of  my  one  hundred  and  fifteen  cases 
were  affected  with  prolapse,  the  affection  is  common  among  the 
uterine  diseases  of  the  menopause.  It  occurs  even  in  the  virgin. 
Of  this  I  remember  having  seen  two  cases.  Borner  (loc.  cit.,  p.  64) 
cites  the  following  case:  "Miss  G.  had  passed  the  menopause  about 
ten  years  before.  She  had  been  free  from  any  sort  of  abdominal  dis- 
turbances during  her  entire  life.  She  was  in  good  health,  although 
incommoded  recently  by  getting  fat.  Shortly  before,  she  happened 
to  be  assisting  in  moving  a  chest,  something  she  had  done  many 
times  previously,  when  she  felt  suddenly  a  pain  in  the  abdomen,  and 
at  once  noticed  a  foreign  body  between  her  thighs.  Soon  after  she 
consulted  me  and  I  found  a  total  prolapse  of  the  uterus  and  vagina 
while  in  every  other  respect  the  genitals  were  intact.  The  patient 
was  a nullipara  and  had  accordingly  an  uninjured,  firm  perineum; 
the  vagina,  already  somewhat  narrowed  by  senile  shrinking,  was 
absolutely  free  from  those  changes  (hypertrophy,  a  dry  leathery  feel 
of  some  portions,  etc.)  which  would  have  pointed  to  a  procidentia 
of  long  .standing;  the  uterus  was  already  atrophied  and  was  small, 
light  and  thin-walled,  and  the  cervix  was  absolutely  intact." 
Such  a  case  must  be  explained  by  increased  intra-abdominal 


THE  MENOPAUSE  621 

pressure  coupled    with   the   atrophic    conditions    of   the   uterine 
organs  just  described  that  favor  prolapse. 

Cystocele  and  rectocele  are  frequently  found  at  the  menopause 
because  of  the  weakening  of  the  vagina  by  atrophic  changes  in  its 
walls;  therefore  the  walls  are  more  apt  to  become  pouched  during 
the  climacteric  than  they  are  previously  when  the  muscular  and 
tendinous  tissues  of  the  perineum  and  vaginal  walls  are  in  a  tonic 
condition. 

Vaginitis  and  Injuries  of  the  Vagina  from  Coitus. — A  discussion  of 
senile  vaginitis  will  be  found  in  Chapter  XX.,  p.  365.  Infection  and 
inflammation  of  the  atrophic  vagina  are  not  infrequently  met  during 
the  menopause.  The  disease  is  more  common,  however,  as  a  so- 
called  post-climacteric  phenomenon  and  will  be  considered  under 
the  diseases  of  old  age.  As  previously  stated,  the  non-elastic  atro- 
phic vagina  may  be  excoriated  or  even  torn  as  a  result  of  coitus. 
Chadwick  reported  a  case  of  this  sort  in  which  a  woman  forty-eight 
years  old,  who  had  not  menstruated  for  about  ten  years,  indulged 
in  sexual  intercourse  after  having  refrained  from  it  for  four  months, 
with  a  result  that  she  had  violent  pain  and  profuse  hemorrhage. 
Examination  showed  a  recent  tear  an  inch  long  in  the  upper  third 
of  the  vagina,  extending  into  the  cellular  tissues  to  a  depth  of  half 
an  inch.  The  vagina,  on  account  of  senile  atrophy,  was  consider- 
ably shorter  and  narrower  than  in  the  childbearing  period. 

Eczema  or  pruritus  vulvae  was  noted  eight  times  in  my  list  of 
cases  and  I  remember  having  found  these  affections  rather  fre- 
quently during  the  menopause  in  dispensary  practice.  They  may 
occur  at  other  times  and  they  are  more  frequently  met  in  the  post- 
climacteric  period, — in  old  age, — than  during  the  menopause. 
Pruritus  may  be  independent  of  any  known  pathological  lesion  of 
the  skin  of  the  vulva,  and  is  thought  often  to  be  a  local  manifes- 
tation of  a  lesion  of  the  general  nervous  system. 

Vesical  Symptoms. — Urinary  symptoms  were  noted  in  twenty- 
three  of  my  cases.  The  symptoms  included  frequent  micturition, 
painful  micturition,  and  incontinence  of  urine.  A  detailed  analysis 
of  the  different  diseases  present  is  hardly  worth  while  in  such  a 
small  number  of  cases.  The  following  were  noted,  however: 
urethritis,  cystitis,  dislocation  of  the  urethra  downward,  and  four 
cases  of  urethral  caruncle.  The  menopause  might  act  as  a  causative 
agent  indirectly  in  producing  urinary  difficulties  by  the  exaggera- 


622  THE  MENOPAUSE  AND  OLD  AGE 

tion  of  preexisting  malpositions  and  traumatisms  due  to  child- 
bearing,  or  through  the  atrophy  of  the  labia  pudendi  and  the  labia 
urethne  offering  more  easy  access  of  pathogenic  bacteria  to  the 
canal  of  the  urethra.  In  addition  to  the  local  causative  agents  the 
unstable  equilibrium  of  the  nervous  system  at  the  menopause  is 
to  be  reckoned  with  when  considering  the  function  of  urination. 
How  much  the  derangement  of  function  is  caused  by  actual  disease 
of  the  urinary  organs,  and  how  much  by  disorder  of  the  general 
nervous  system,  we  find  most  difficult  to  state  in  many  actual 
cases  in  practice.  My  observation  leads  me  to  the  view  that  the 
situation  is  the  same  with  the  urinary  apparatus  as  with  the  uterine 
organs;  that  preexisting  disease,  or  impairment  of  function,  causes 
a  stormy  change  of  life ;  that  unsound  organs  which,  while  nourished 
by  a  well-equalized  blood  supply,  cause  only  minor  symptoms, 
under  changed  conditions  cry  out  loudly.  Therefore,  let  it  be  our 
aim  to  discover  the  abnormalities  of  the  genital  organs  during  the 
period  of  sexual  maturity  in  the  life  of  our  patients  and,  by  treating 
the  diseases,  help  the  patients  to  avoid  many  of  the  discomforts 
of  the  menopause. 

OLD  AGE 

Bichat,  writing  in  1800,  said:  "The  man  who  has  reached  the 
end  of  a  long  career  dies  in  detail;  his  visible  functions  end  one 
after  the  other."  Woman  apparently  grows  old  faster  than  man  and 
the  exact  reason  can  not  be  found.  Women  of  tropical  climes 
reach  senility  sooner  than  those  of  northern  latitudes,  just 
as  the  exuberance  of  vegetation  in  the  torrid  zones,  after  a 
season  of  forcing,  comes  to  a  climax  and  dies  earlier  than  in  the 
slower  growth  of  the  temperate  regions.  Hereditary  predisposition 
of  the  individual  to  prolonged  life,  or  to  the  longevity  of  certain 
functions  of  body  or  mind,  must  be  considered  in  making  a  diagnosis 
and  a  prognosis  in  the  case  of  any  disease  of  advanced  life.  The 
menopause  represents  a  phase  of  life  which  is  introductory  to  old 
age.  It  is  not,  however,  a  part  of  old  age,  and,  as  has  been  said 
already  in  treating  that  period  of  life,  is  not  to  be  credited  with 
all  the  atrophic  changes  in  the  organs  of  the  body  which  occur  with 
advancing  years.  A  good  deal  is  said  in  the  literature  of  the  "post- 
climacteric  phenomena."  At  the  beginning  of  this  chapter  we 


OLD  AGE  623 

adopted  the  age  of  sixty  years  as  an  arbitrary  point  for  the  be- 
ginning of  old  age,  and  although  some  of  the  post-climacteric 
changes  in  the  organs  of  the  body  must  in  single  instances  antedate 
this  age,  still  this  mark  is  as  good  as  any  other  for  our  purpose. 

This  is  not  the  place  for  a  discussion  of  the  alterations  which 
take  place,  as  a  result  of  age,  in  the  tissues  and  in  the  function  of 
the  heart  and  blood-vessels,  the  spleen,  the  thyroid  and  the  supra- 
renal capsules,  the  nervous  system,  the  digestive  canal,  the  kidneys, 
the  liver,  the  lungs,  the  skin,  and  the  general  nutrition.  For  an  able 
exposition  of  these  important  considerations  the  reader  is  referred 
to  Professor  G.  Rauzier's  "Traite  des  Maladies  des  Vieillards," 
(Paris,  1909).  Here  it  will  be  sufficient  to  call  attention  briefly 
to  alterations  in  the  structure  and  function  of  the  genito-urinary 
system  in  old  age.  The  senile  changes  in  the  breasts  have  been 
referred  to  in  Chapter  XXVII,  page  531. 

The  Ovaries. — The  ovaries  are  withered  and  have  a  cicatricial 
aspect,  and  finally  shrivel  to  little  knobs  of  connective  tissue 
containing  a  few  cysts  in  the  outer  portions  where  formerly  was 
the  cortical  zone.  Ovarian  tumors  not  infrequently  develop  in 
old  age  and  cases  have  been  reported  by  many  observers  where 
cystomata  developed  after  the  age  of  sixty,  notably  those  re- 
ported by  Johnson  l  who  operated  on  a  woman  sixty-four  years 
old,  Davis  2  at  the  age  of  sixty-five,  Spencer  Wells  3  and  J.  Boeckel 4 
at  seventy-three,  Josephson  5  at  seventy-six,  F.  Terrier 6  at  sev- 
enty-seven, E.  M.  Owen  7  at  eighty,  and  John  Homans  8  at  eighty- 
two  years,  four  months.  The  last  author  (Three  hundred  and 
eighty-four  laparotomies,  1887)  in  the  course  of  two  hundred 
and  eighty-two  ovariotomies,  removed  ovarian  tumors  from  one 
woman  aged  seventy-two  and  three  aged  seventy-three  years. 

The  Fallopian  Tubes. — The  Fallopian  tubes  are  deprived  of  their 
lining  epithelium,  they  shrink  in  all  their  dimensions,  finally  the 
lumen  is  obliterated,  and  they  become  mere  cords  of  connective 

1  Virginia  Med.  Monthly,  1888,  Vol.  XV.,  p.  644. 
-Brit.  Med.  Journ.,  1887,  Vol.  II.,  p.  1050. 
3  "Tumours  of  the  Ovary,"  1888. 
*Goz.  Med.  de  Strasbourg,  1896,  p.  26. 
^Centralblattfiir  Gyn.,  1889,  No.  47,  p.  824. 
6Pro(jr<-8  Mid.,  1888,  No.  24,  p.  466. 
''Brit.  Med.  Journ.,  1888,  Vol.  IX.,  p.  38. 
8  N.  Y.  Med.  Rcc.,  May  5,  1888,  p.  496. 


624  THE  MENOPAUSE  AND  OLD  AGE 

tissue.  Diseases  of  the  tubes  are  extremely  rare  in  old  age.  Chron- 
ically inflamed  tubes  necessarily  can  not  undergo  the  retrograde 
changes  as  readily  as  healthy  tubes.  But,  as  a  matter  of  clinical 
observation,  diseased  tubes  generally  cause  symptoms  during  the 
childbearing  period  of  life,  exceptionally  during  the  menopause, 
and  almost  never  in  old  age. 

The  Uterus. — The  uterus  becomes  lessened  both  in  volume  and 
in  weight  as  a  result  of  retrograde  changes  in  its  structure  and  only 
when  chronic  metritis  during  menstrual  life  has  converted  the 
muscular  structure  of  the  organ  into  connective  tissue  and  elastic 
tissue  is  its  volume  greater  than  normal.  Aran  found  that  after 
seventy  years  the  uterus  diminished  in  length  from  2|  inches  (68 
millimeters)  to  2|  inches  (57  millimeters)  and  in  thickness  from 
1T^- inches  (43  millimeters)  to  ly9^  inches  (40  millimeters).  According 
to  his  observation  the  weight  of  the  organ  diminished  in  the  case  of 
the  virgin  uterus  from  45  grammes  to  35  grammes,  and  in  the  case  of 
the  parous  uterus  from  70  grammes  to  60  grammes.  Ordinarily  this 
amount  of  diminution  both  in  dimensions  and  in  weight  is  rather 
below  the  normal,  and  other  observers,  notably  Arnal  (Weinberg 
and  Arnal,  Mem.  Soc.  Anatom.,  May,  1905),  who  found  a  senile 
uterus  which  weighed  11.5  grammes,  have  reported  finding  a 
smaller  organ  after  atrophic  changes  are  well  advanced.  The 
walls  of  the  uterus  are  diminished  in  thickness  and  the  cavity  is 
reduced  in  all  its  dimensions.  The  cervix  generally,  unless  hin- 
dered by  lacerations  and  thickenings,  withers  more  than  the  body 
of  the  uterus.  The  internal  os  of  the  senile  uterus  is  commonly 
found  closed,  probably  because  of  the  disproportionate  atrophy  of 
the  cervix,  the  os  being  stenosed  either  by  a  thin  diaphragm  or  by 
the  formation  of  a  ring  of  sclerotic  tissue  formed  in  this  situation. 
Guyon  (Thesis,  Paris,  1858)  found  the  os  closed  in  thirteen  out  of 
twenty  cases  he  observed,  and  Arnal  (loc.  eft.)  found  obliteration 
in  sixteen  cases  and  a  partial  stricture  in  five  out  of  forty-one  cases. 
Occasionally  the  external  os  is  found  closed  also.  If  the  cervical 
canal  is  closed  the  uterus  generally  contains  a  variable  quantity 
of  mucus.  I  have  known  of  two  cases,  neither  of  them  due  to  cancer, 
in  which  the  uterine  cavity  was  converted  into  an  abscess  cavity. 
As  a  rule  the  atrophic  uterine  mucosa  of  the  senile  uterus  is  covered 
with  a  thick,  yellowish-white  mucus.  The  mucous  membrane  is 
thinned  and  contains  in  its  structure,  often,  hemorrhagic  areas  or 


OLD  AGE  625 

small  cysts,  and  its  surface  is  wrinkled  so  that  the  appearance  of 
hypertrophy  is  given  to  it. 

Senile  endometritis,  which  is  sometimes  present,  has  been  de- 
scribed in  Chapter  XL,  p.  183. 

Cancer  originates  in  the  senile  uterus, — more  frequently  cancer 
of  the  body,  and  less  frequently  cancer  of  the  cervix, — the  latter 
being  a  disease  rather  of  the  menopause.  Any  bloody  vaginal 
discharge  or  a  watery  leucorrhea  in  an  old  woman  should  arouse 
the  suspicion  of  cancer  in  the  mind  of  the  practitioner,  and  should 
lead  to  a  thorough  local  examination. 

The  Vagina. — The  vagina,  as  was  pointed  out  in  the  section  of 
this  chapter  on  the  menopause,  undergoes  certain  changes  at  the 
menopause  which  persist  in  old  age,  becoming  more  marked  after 
the  latter  period  of  life  is  well  advanced.  The  vagina  is  shortened, 
cone-shaped  because  of  excessive  atrophy  -in  its  upper  portion, 
its  walls  are  thinned  and  non-elastic.  Later  in  life  the  diminution 
in  caliber  may  be  so  great  as  to  make  coitus  impossible.  The 
atrophied,  thinned  mucosa  may  be  the  seat  of  inflammation. 
Senile  vaginitis,  which  is  described  in  Chapter  XX.,  p.  365,  is  a  very 
common  affection  and  often  results  in  adhesions.  The  symptoms 
consisting  of  a  burning  sensation  in  the  vagina,  dyspareunia,  a 
feeling  of  weight  in  the  pelvis  accompanying  a  thin  irritating  leu- 
corrhea, are  not  characteristic.  The  diagnosis  is  made  by  a  local 
examination. 

The  Vulva. — The  vulva  shows  signs  of  marked  atrophy  in  old 
age.  The  hair  of  the  mons  veneris  and  labia  majora  becomes 
gray  and  scanty.  The  fat  under  the  mons  and  in  the  labia  dis- 
appears gradually  after  the  post-climacteric  period  of  hypernu- 
trition  has  been  passed,  and  the  labia  become  flabby  and  wrinkled 
so  that  they  no  longer  come  together  firmly  in  the  median  line. 
Therefore  the  vulva  gapes  in  varying  degrees  in  different  indi- 
viduals, and  the  openings  of  the  vagina  and  urethra  are  not  so  well 
protected  from  infection  as  in  the  younger  woman.  The  mucous 
membrane  of  the  vestibule  is  glassy,  thin  and  smooth,  and  may 
show  areas  of  ecchymosis. 

Pruritus  vulva*  (see  Chapter  X.,  p.  160)  is  a  common  affection, 
so  are  various  dermatoses  of  which  eczema  is  the  most  common. 
Kraurosis  vulva1  may  occur  in  the  aged,  and  primary  cancer  has 
been  found  very  rarely  in  the  vulva  at  this  time  of  life.  [i] 

40 


INDEX 


ABDOMEN,  auscultation  of,  72 

cavity  of,  shape  of,  Fig.  86,  221 

division  of,  into  quadrants  and  in- 
dication of  bony  landmarks,  Fig. 
18,  65 

gauze  records  of,  74,  Fig.  20,  75 

in  late  pregnancy,  appearance  of,  427 

inspection  of,  64 

mensuration  of,  74 

in  case  of  ovarian  tumors,  304 

organs  of,  origin  of  tumors  in,  Fig. 
129,  304 

palpation  of,  68 

percussion  of,  71 

skin  of,  appearances  of,  66 

swelling  of,  in  case  records,  8 
in  clinical  history,  20 

walls  of,  fat  in,  differentiated  from 

ovarian  tumor,  310 
fibromyoma  of  rectus  muscle   in, 

310 
movements  of,  66 

with  ascites,  cross-section  of,  dorsal 

position.  Fig.  132,  310 
lateral  position,  Fig.  133,  311 
Abortion,  diagnosis  of,  436 

etiology  and  frequency  of,  437 

inevitable,  diagnosis  of,  439 

oxy toxic  drugs  a  cause  of,  437 

partially  or  wholly  completed,  diag- 
nosis of.  440 

symptoms  of,  438 

syphilis,  a  cause  of.  437 

threatened,  diagnosis  of,  439 

varieties  of,  definitions  of,  436 
Abscess,  anal.  514 
submiK'ous.  515 

appendiceal.  differentiated  from  pel- 
vic cellutitis,  196 

ischio-rectal.  515 

mammary.  542 

pelvic.  193 

mapped  out  by  bimanual  touch.  42 

627 


Abscesss,  pelvi-rectal,  515 

psoas,     differentiated     from    pelvic 

cellulitis,  196 
sub-mammary,  542 
sub-urethral,  differentiated  from  cys- 

tocele,  368 
from  dislocation  of  urethra,  447 

Absence  of  any  organ  (see  organ  speci- 
fied) 

Acetonemia,  odor  of  breath  in,  61 

Acetonuria,     in      extra-uterine    preg- 
nancy, 353 

Acromegaly,  attended  by  amenorrhea, 
419 

Actinomyces.     See     Salpingitis,    acti- 
nomycotic 

Acute  diseases,  a  cause  of  sterility,  151 

Address,  in  clinical  history,  9 

Adhesions,  a  result  of  pelvic  peritonitis, 

192 

and    incarceration    of    ovarian    tu- 
mors, 315 

Age,  in  clinical  history,  9 

Alcoholism  a  cause  of  sterility,  151 

Alligator  bladder  forceps,  Fig.  50,  105 
rectal  forceps,  Fig.  62,  125 

Amenorrhea,  139 

as  a  symptom  of  pregnancy,  419 
primary,  139 
secondary,  141 

Ammonia    coefficient    in    vomiting   of 
pregnancy,  435 

Ampulla  of  Fallopian  tube,  Fig.   116, 
285 

Anal  canal,  anatomy  of,  122 

region,  diagram  of,  Fig.  195,  515 

Anatomy  of  organ.      See  organ  speci- 
fied 

Anemia,  a  cause  of  sterility,  151 
in  fibroid  tumors,  258,  261 

Anomalies.     See  organ  affected 

Anteflexion.   See  Uterus,  anteflexion  of 

Anuria,  156 


628 


INDEX 


Anus,  abnormally  small,  498 

abscess  in,  514 

at  third    month    of    fetal  life,  Fig. 
157,  392 

canal  of,  Fig.  150,  373,  Fig.  191,  495 

cast  of,  Fig.  192,  490 

cancer  of,  52G 

chancre  of,  511,  512 

chancroids  of,  511,  512 

condylomata  lata  of,  512 

development  of,  Figs.  158-162,  395 

eversion  of,  for  inspection  of  hem- 
orrhoids, 502 

fissure  of,  503 

gumma  of,  512 

imperf orate,  497,  561 

inspection  of,  121 

lipoma  of,  523 

mucous  patches  of,  511 

papilloma  of,  522 

protrusion  from,  as  a  symptom,  158 

soft  fibroma  of,  523 

syphilis  of,  510 

syphilitic  ulcerations  of.  512 

tuberculosis  of,  513 

vaginalis,  393 
Anxiety,  polyuria  in,  485 
Appendicitis   differentiated    from    sal- 

pingitis,  336 

Applicator,  uterine,  Fig.  37,  93 
Apprehension,  a  cause  of  polyuria,  485 
Arbor    vita;    of    cervical     canal,    204, 

209 
Areola,  anatomy  of,  421,  532 

primary,  421,  532 

secondary,  426,  535 
Arnal,  views  of,  on  diminution  in  size 

of  uterus  in  old  age,  624 
Arterial  tension,  high,  in  menopause, 

613 

Arteriosclerosis,  menorrhagia  in,  136 
Ascites,   abdomen   of,    seen    in    profile, 
Fig.  131,  307 

differentiation  of,   from   fibroid,  263 
from  ovarian  cyst,  30S 

encysted,  308 
Auscultation  of  abdomen,  72 

BACKACHE.  IS 
Bacteriuria  in  children.  579 


Ball,  Sir  Charles,  case  of  absence  of 

rectum,  496 

Ballantyne  and  Thompson,  cases  of 
prolapse  of  uterus  in  infants,  562 

Ballottement,  external,  429 
internal,  427 

Barker,  Fordyce,  cases  of  late  child- 
bearing,  602 

Bartholinitis,  409 

Bartholin's  glands,  abscess  of,  409,  Fig. 

176,  411 

abscess  of  ducts  of,  Fig.  175,  410 
anatomy  of,  391 
cancer  of,  414 

collection  of  discharges  from,  61 
cyst    and     abscess    of,    differential 

diagnosis  of,  412 
cyst  of,  differentiated  from  entero- 

cele,  371 

differentiated  from  hernia,  413 
cyst  of  left,  Fig.  174,  409 
cysts  of,  408 
lurking  places  in,  for  infection,  180 

Baudelocque.     See    Pelvis,    conjugate 

diameter  of 

cases  of    regular  menstruation  dur- 
ing pregnancy, 469 

Baumgarten  and  Poffer  on  acetonuria 
in  extra-uterine  pregnancy,  353 

Bearing-down  feeling,  19 

Bender,  X.,  and  Lardennois,  G.,  ob- 
servations that  fibroids  may  be  in- 
vaded by  cancer  metastases,  255 

Berger,  II.,  cases  of  melancholia  at 
menopause,  615 

Bichat,  observations  on  old  age,  622 

Bimanual  touch.  See  Touch,  bi- 
manual; also  Palpation,  bimanual 

Bladder,  absence  of,  457 
adenoma  of,  483 
anatomy  of,  101 
anomalies  of,  457 
base   of,    showing    diverticula,    Fig. 

185,  458 
calculus  of,  462 

in  children,  582 
cancer  of,  483 

capacity  of,  measurement  of,  109 
catheterization  of,  108 
dome  spasm  of,  109 


INDEX 


629 


Bladder,   contracted,   a  cause   of    fre- 
quency of  micturition,  154 

contraction  of,  461 

development  of,  Fig.  71,  198,  Figs. 
158-162,  395 

diseases  of,  457 
in  children,  578 

displacement  of,  downward,  461 
lateral,  462 
upward,  461 

distended,    459.     See    also  Bladder, 

overdistended 
differentiated   from  large  ovarian 

tumor,  314 

differentiated  from  small  ovarian 
tumor,  300 

diverticulum  from,  458 

double,  458 

eversion  of,  through  urethra,  462 

exstrophy  of,  459 

fibroma  of,  483 

fistula}  of,  474.    See  also  Fistula 

foreign  bodies  in,  463 

functional  disturbances  of,  151,  484 

hernia  of,  462 

hypertrophy    of    wall     of,    differen- 
tiated from  cystocele,  368 

inflammation  of,  465 

irritability  of,  485 

landmarks  in,  103 

loculate,  458 

myoma  of,  483 

new  growths  of,  480 

normal,  laid  open  from  the  front,  Fig. 
51,  106 

overdistended,  incontinence    in,  154 
shape  of.  Fig.  84o,  217 

papilloma  of.  482.  Fig.  190.  482 

primary  tumor  of.  in  children,  582 

removing    urine    from,    by    suction 
apparatus.  Fig.  55.  113 

rupture  of,  460 

in  retroflexion    and    incarceration 
of  pregnant  uterus,  432 

sarcoma  of.  4X4 

stammering  of.  10'.).  405 

stone  in,  462.  Fig.  186.  463 
in  children.  5S2 

tuberculosis    of    uretoral    orifice    in. 
Fig.  1S7.  469 


Bladder,  vagina  and  rectum  ballooned 
by  air,  in  examination  of,  Fig.  54, 
112 

varicose  veins  of,  474 
varix  of,  474,  Fig.  188,  474 
wall  of,  drumming  of,  465 

hypertrophy  of,  differentiated  from 

cystocele,  368 
thickening  of,  a  cause  of  stricture 

of  ureter,  489 

Bladder  phantom,  Fig.  58,  118 
Bladder  symptoms,  151,  484 
in  case  records,  7 
in  clinical  history,  20 
Bland-Sutton,    case    of    frequent    hot 

flashes  in  menopause,  613 
case  of  multiple  seedling  fibroids,  244, 

251 

on  hydatid  fremitus,  299 
on  myomatous  affection  of  Fallopian 

tubes,  338 
on  ovariotomy  performed  on  children, 

576 

Blood  pressure  in  menopause,  613 
vessels,  uterine  and  ovarian,  Fig.  8, 

47 
Bloodgood,     J.     C.,     classification     of 

diseases  of  the  breast,  536 
on  sarcoma  of  the  breast,  549,  551 
Blum,  case  of  three  mammae,  538 
Boils  of  vulva,  407 

Bokai,  case   of  ligation  of  clitoris,  575 
statistics  of  rectal  prolapse  in  chil- 
dren, 584 
Boldt,  H.  J.,  views  on  severe  grades  of 

exfoliative  cystitis,  468 
Bondi,  J.,  on  varieties  of  cysts  of  the 

labia  minora,  413 
Bonney,  C.   W.,   cases  of  rupture  of 

pyosalpinx,  333 
Borner,  case  of  premature  menopause, 

600 

case  of  unexplained  flowing  at  meno- 
pause, 619 

case  of  prolapse  in  virgin  at  meno- 
pause, 620 
is  ovulation  abolished  with  cessation 

of  menstruation?  599 
Bowels,  in  case  records,  8 
in  clinical  history,  21 


630 


INDEX 


Bozeman  dressing  forceps,  83 
Bozeman-Fritsch  uterine  irrigator,  Fig. 

35,  92 
Brain,  disease  of,  cause  of  incontinence 

of  urine,  155 
Breast,  absence  of.  538 
adenocarcinoma  of,  546 

with  papilloma  in  the  cysts,  546 
age  changes  of,  534 
anatomy  of,  533 
areola  of,  anatomy  of,  421.  532 

primary,  in  early  pregnancy,  421 

secondary,  426,  535 
cancer  of,  545 
cancer  cysts  of,  548 

differentiated     from      galactocele, 

548 

colloid  adenocarcinoma  of,  546 
colostrum  in,  427 
comedoadenocarcinoma  of,  546 
cyst  of,  simple,  540 

differentiated  from  cancer  cyst, 

541 

cystic  adenocarcinoma  of,  546 
development  of,  incomplete,  538 
diseases  of,  531 

classification  of,  536 
dissection  of  lower  half  of,  showing 

milk  ducts.  Fig.  198,  534 
division  of,  into  quadrants,  Fig.  200, 

538 
enlarged  glands  in  axilla,  a  sign  of 

tumor  or  inflammation  of,  553 
enlarged    supraclavicular   glands    in 

late  cancer  of,  554 
fullness  of,  a  symptom  of  pregnancy, 

420 

galactocele  of,  539 
hypertrophy    of,    diffuse     bilateral, 
540,  Fig.  201,541 

in  puberty,  535 

infantile,  539 

lactation,  535 

senile  parenchymatous,  540 
in  early  pregnancy,  421 
in  lat:>  pregnancy.  426 
infantile,  534 
inflammations  of,  542 
lactation  hypertrophy  of,  535 
late  cancer  of.  cachexia  in,  554 


Breast,  late  cancer  of,  discharge  from 
nipple  in,  553 

enlarged  supraclavicular  glands  in, 
554 

metastases  to  other  organs  in,  553 

signs  of,  553 

skin  metastases  in,  553 

nice  ration  of  skin  in,  553 
lymphatic  glands  of  axilla,  enlarged 

in  inflammation  of,  553 
lymphatics  of,  Fig.  199,  535 
medullary  carcinoma  of,  546 
milk  ducts  of,  532 
neuralgia  of,  539,  553 
nipple  of,  anatomy  of,  532 

discharge  from,  in  late  cancer,  553 

discharge  of  blood  from,  545,  546 

Paget's  disease  of,  548 

retraction  of,  553 
of  puberty,  535 
pain  in,  553 
phantom  tumor  of,  539 
rheumatism   of  pectoral   muscle  in, 

553 
right,  vertical  section  of,  Fig.   197, 

533 

sarcoma  of,  549 

scirrhous  cancer  of,  Fig.  202,  547 
scirrhous  carcinoma  of,  548 
senile,  536 

supernumerary  mamma1  of,  538 
symptomatic  lesions  of,  539 
syphilis  of,  544 
tumors  of,  age  as  affecting,  550 

diagnosis  in  general  of,  549 

duration  of,  551 

early  diagnosis  in,  549 

history  as  affect  ing  diagnosis  of,  550 

mobility  of.  552 

rare  forms  of,  537 

situation  of,  551 

varieties  of:    adenoma,  cystic.  545 
adenofibroma.  544 
cancer.  545 

average  duration  of  life  in.  545 
fibro-epithelial.  544 
myxoma.  intracanalicular,  544 
papilloma.  intracystic,  545 
veins  of.  enlarged  in  early  pregnancy, 

421 


INDEX 


631 


Brewer  bivalve  speculum,  Fig.  26,  87 
Broad     ligaments.      See      Ligaments, 

broad 
Burrage  uterine  speculum,  Fig.  36,  93 

used  in  packing  uterus,  96 

CABOT,  A.  T.,  case  of  horny-celled  cys- 
titis, 470 

Calibrator,  meatus,  Kelly,  Fig.  44,  101 
Campbell,    R.    P.,    on    the    diagnostic 
significance  of  spirocha'tapallida,  407 
Canal,  anal,  Fig.  191,  495 
Canavan,   M.    M.,    case    of   ulcerative 
vaginitis  in  bacillary  dysentery,  364 
Cancer.     See  Organ  affected 
Cancer   and    fibroids,    to   be   excluded 
from  statistics    on    the   menopause, 
590 

Can tha rides,  a  cause  of  cystitis,  467 
Capacity  of  bladder,  109 

of  pelvic  cavity,  98 
Carcinoma.     See    Cancer    and     organ 

affected 

Caruncle.     See  Urethra 
Carunculse  myrtiformes,  Fig.  165,  397 
Case-record  system,  6 
Case-records,  form  for,  6 
Casper,  on  appearances  of  bladder  by 

indirect  cystoscopy,  117 
Catheter,  bladder,  long,  Fig.  43,  101 

ureteral,  Kelly,  Fig.  48,  103 
Catheterization  in  children,  578 
of  bladder.  108 
of  ureters,  115 

caution  against,  479 
Cauliflower  growth.     See  Cervix,  can- 
cer of 
Causation  of  disease  in  any  organ.     See 

organ  affected 

Cellular  tissue,  pelvic,  anatomy  of,  192 
Cellulitis,  pelvic,  192 
diagnosis  of,  194 
differential  diagnosis  of,  195 
differentiated     from     appendiceal 

abscess.   196 

from  pelvic  hematocele,  196 
from  pelvic  peritonitis,  195 
from  psoas  abscess,  196 
from  pyosalpinx,  196 
from  subserous  myoma,  196 


Cellulitis,    etiology  and   pathology  of, 

192 

symptoms  of,  193 
Cervicitis.     See  Endocervicitis 
Cervix,  adenocarcinoma   of,   diagnosis 

of,  275 

differential  diagnosis  of,  276 
adenocarcinoma  of  canal  of,  268 

early  stage  of,  Fig.  Ill,  268 
anatomy  of,  204 
appearance  of,  in  early  pregnancy, 

422 

atrophy  of,  at  menopause,  594 
canal  of,  collection  of  discharges  from, 

62 
cancer  of,   a   cause  of  stricture   of 

ureter,  489 

cauliflower  growth,  271 
diagnosis  of,  271 
differential  diagnosis  of,  272 
differentiated  from  erosion,  186 

from  fibroid,  265 
early  stage  of,  Fig.  110,  267 
infiltrating,  272 
squamous-celled,  267 

early  stage  of,  Fig.  110,  267 
ulcerating,  272 
chancre      of,     differentiated     from 

erosion,  186 
chancroids    of,    differentiated    from 

cancer,  275 
from  erosion,  186 
condylomata  of,  differentiated  from 

cancer,  273 
elongation  of,  hypertrophic,  Fig.  88a, 

225 

case  of  Huguier,  225 
differentiated  from  prolapse,  229 
false,  209 
erosions  of,  184 

cause  of  sterility,  150 
differentiated  from  cancer,  274 
from  cancerous  ulceration,  186 
from  chancre,  186 
from  chancroid,  186 
from  tuberculous  ulcer,  186 
from  ulceration,  186 
follicular,  185 
in  children,  563 
papillary,  185 


032 


INDEX 


Cervix,  erosions   of,  purple  in  color  in 

early  pregnancy,  422 
simple.  184 
with  lacerations,  Fig.  69,  185 

fibroids  of,  247 

follicles  of,  hypertrophied,  differen- 
tiated from  cancer,  273 

gumma  of,  differentiated  from  cancer, 
275 

hypertrophic  elongation  of,  true,  225, 
229 

inflammatory  thickening  of,  differen- 
tiated from  cancer,  273 

lacerated,  a  cause  of  hemorrhage  at 
menopause,  618 

lacerations  of,  204 

a  cause  of  sterility,  150,  151 
bilateral,  Fig.  79,  205 

with  eversion  of  lips,  Fig.  82,  208 
crescentic.  Fig.  81,  207 
differential  diagnosis  of,  210 
etiology  of,  204 

mechanism  of  production  of,  205 
old,  209 
recent,  208 
results  of,  206 
stellate,  Fig.  80,  206 
unilateral,  Fig.  83,  209 

mucous     polypi     of,     differentiated 
from  cancer,  273 

myoma  of,  differentiated   from  can- 
cer, 273 

of  purplish  color  in  early  pregnancy, 
422 

papillary    tuberculosis    of,   differen- 
tiated from  cancer,  273 

removal  of  tissue  from,  for  examina- 
tion, 62 

sarcoma  of,  280 

syphilis  of,  differentiated  from  can- 
cer, 275 

tuberculosis  of,  differentiated   from 
cancer,  273 

ulcer  of,  from  papule,  differentiated 

from  cancer,  275 
simple,  differentiated  from  cancer, 

274 

from  erosion,  186 
tuberculous,    differentiated     from 
cancer,  274 


Cervix,  tuberculous,  differentiated  from 

erosion,  186 
Chancre.     See  Vulva,  Vagina,  Cervix, 

Anus,  and  Urethra,  chancre  of 
Chancroids.     See  Vulva,  Vagina,  Cer- 
vix, and  Anus,  chancroids  of 
Change  of  life.     See  Menopause 
Chiene,  ovariotomy  on    three-months- 
old  child,  293 
Child,  new-born,   longitudinal  median 

section  of,  Fig.  204,  558 
Childbearing,  in  case  records,  7 

late,  601 
Childhood,  gynecological  affections  of, 

555 
Children,  examination  of,  556 

number  of,  in  clinical  history,  11 
Chlorosis,  amenorrhea  a  symptom  of, 

419 

Cholemia,  menorrhagia  in,  135 
Chorioepithelioma.     See  Uterus,  Vagi- 
na, and  Tube,  Fallopian 
Chromocystoscopy,  119 
Chute,  A.  L.,  case  of  infected  diverticu- 

lum  of  bladder,  458 
Claisse,  A.,  theory  as  to  etiology  of 

fibroids,  250 

Cleanliness  in  vaginal  examinations,  28 
Climacteric.     See  Menopause 
Clitoris,  Fig.  156,  389 

anatomy  of,  390 

at  third  month  of  fetal  life,  Fig.  157, 
392 

malformations  of,  393 

prepuce  of,  adherent,  557 
Cloaca,  Fig.  159,  395 
Clothing,  loosening  of,  as  preparation 

for  examination,  24 
Clover  crutch  leg-holders,  57 
Coccygodynia,  159 

in  clinical  history,  19 
Coccyx,  pain  in,  159 
Coitus,  barred  by  vaginismus,  379 

excessive,  a  cause  of  abortion,  437 
of  cystitis,  467 
of  sterility,  151 

injuries  of  hymen  due  to,  401 
of  vagina  due  to,  376 

painful,  146 

through  dilated  urethra,  444 


INDEX 


633 


Coitus,  unnatural,   a  cause  of  gonor- 

rheal  proctitis,  510 
Collection  of    tissues    and  discharges, 

61 

Colostrum.     See  Breast 
Colpitis,  361 

Combined  vagino-abdominal  touch,  38 
Comby,  J.,  on  vulvar  hemorrhages  in 

little  girls,  572 
Complaint,  chief,  in  clinical  history,  7, 

12 
Conception,  factors  essential  for,  149 

late  in  life,  601 

without  sexual  feeling,  149 
Condylomata,     acuminata    and    lata. 

See  Vulva  and  Anus 
Congenital  anomalies  and    malforma- 
tions.    See    organ    affected,  anom- 
alies and  malformations  of 
Congestion,  pelvic,  a  cause  of  leucor- 

rhea,  145 

of  menorrhagia,  135 
of  sterility,  151 

Conjugate  diameter  of  pelvis,  96 
Constipation,  a  cause  of  fissure  in  ano, 

503 

of  hemorrhoids,  500 
of  retroversion,  236 

in  clinical  history,  21 
Controller,  current,  Fig.  57,  117 
Cord,  spinal,  diseases  of,  retention  and 

incontinence  of  urine  in,  485 
Corpus  luteum.     See  Ovary 
Craig,  M.,  views  on  mental  disease  at 

menopause,  615 
Cryptomenorrhea,  139,  140 
Cullen,    T.    S.,    on    adenomyoma    of 

uterus,  245 
Cullingworth    on     hemorrhage   in    the 

new-born,  572 

Cultures,  method  of  taking,  62 
Current  controller.  Fig.  57,  117 
Curette,  uterine.  Fig.  31,  90 

forceps,  Emmet,  Fig.  30,  89 
Curetting,  dangers  of.  93 

technique  of,  90 
Currier,  A.,  on  the  menopause  among 

American  Indians,  588,  598 
Cylinder,  vertical,  likened  to  cavity  of 

abdomen,  Fig.  7.  45 


Cyst.     See  Ovary,  Vagina,  and  Paro- 
varium,  cyst  of 

tubo-ovarian,  334 
Cystitis,  465 

a  cause  of  dysuria,  153 

catarrhal,  467 

chronic,  hypertrophy  of  bladder  wall 
in,  differentiated  from  cystocele, 
368 

classification  of,  466 

cystoscopy  in,  473 

diagnosis  of,  471 

etiology  and  pathology  of,  466 

examination  of  urine  in,  471     . 

exfoliative,  468 

in  children,  581 

palpation  of  bladder  in,  472 

symptoms  of,  471 

tuberculous,  468 

ulcerative,  468 

vesicular,  470 

with  cornified  patches,  470 

with  yellowish  plaques,  471 
Cystocele,  Fig.  148,  366,  367 

at  menopause,  621 

diagram  of,  Fig.  148a,  368 

differential  diagnosis  of,  367 
Cystoscope,  bladder,  Kelly,  Fig.  49,  104 

ureter,  Nitze,  Fig.  56,  116 
Cystoscopy,  direct,  110 

electric,  117 

indirect,  117 

instruments  used  in,  99 

removing  urine  from  bladder  by 
suction  in,  Fig.  55,  113 

D  ALTON,  J.  C.,  case  of  absence  of  corpora 

lutea  in  degenerated  ovaries,  593 
Da  vies,  J.,  case  of  late  child-bearing, 

602 
Davis,  L.,  analysis  of  forty-five  cases  of 

bladder  tumor,  481 
Decidua,     uterine,     in     extra-uterine 

pregnancy.  Fig.  143,  344,  345 
Defecation,  difficulty  in,  as  a  symptom, 

158 

Deformed  pelvis,  95 
Delayed  menopause,  601 
Demme-Granicher,  case  of  fibrosarcoma 

of  vagina  in  a  child,  570 


634 


INDEX 


Depressor,  Hunter,  Fig.  29,  88 
Diabetes,  urine  of,  a  cause  of  pruritus, 

160 
Diagnosis    of     disease    in    any    organ. 

See  organ  affected    and    disease  af- 
fecting 

Diameters  of  pelvis,  96 
Diarrhea  in  rectal  disease,  158 
Digital  examination  of  rectum,  123 

of  vagina,  34 
Digital  exploration  of  uterine  cavity, 

94 

Dilatation  of  uterus,  91 
Dilator,   urethral,    double-ended.    Fig. 
45,  102 

uterine,  Hanks,  Fig.  33,  91 

Wathen,  Fig.  34,  92 
Discharge,  rectal,  157 

in  hypertrophic  proctitis,  509 

vaginal.     See  Leucorrhea 
in  case  records,  7 
in  clinical  history,  18 
Diseases,  constitutional,  causing  amen- 

orrhea, 141 
Doderlein,   lactic    acid,   bacterium   of, 

355 

"Dodging  time"  of  menopause,  611 
Dressing  forceps,  uterine.   See  Forceps 
Drumming  of  bladder,  109,  465 
Ducts,  milk.     See  Breast 

of  Miiller,  197,  Fig.  71,  198 
Dudley,    E.    C.,    tables  of    differential 

diagnoses,  195-196,  308-309 
Dysmenorrhea,  128 

associated  with  pelvic  lesions,  129 

differentiated  from  abortion,  441 

due  to  poor  health,  130 

membranous,  131,  172 

neurotic,  130 

obstructive,  129 

with  fibroids,  129 

with  malformation  of  uterine  organs, 
129 

with  no  pelvic  lesion,  130 

with  pelvic  inflammation,  129 

with   retroposition   and  anteflexion, 

129 
Dyspareunia,  146 

in  clinical  history,  11 
Dvsuria.  151 


EARS,  ringing  in,  in  menopause,  613 
Echinococcus  cyst,  differentiated  from 

large  ovarian  tumor,  314 
from  small  ovarian  tumor,  299 
Ectopic   pregnancy   and   chorioepithe- 
lioina.   See  Pregnancy,  extra-uterine, 
and  Chorioepithelioma,  ectopic 
Edebohls   vaginal   speculum,   Fig.   32, 

91 
Edgar,  J.  C.,  on  frequency  of  abortion, 

437 
Edwards,   W.   A.,    views  on   adherent 

prepuce  in  the  child,  557 
on  malignant  disease  of  the  uterus 

and  ovaries  in  children,  278,  576 
on  masturbation,  575 
Elevated  pelvis  position,  58 
Emmet,  T.  A.,  views  on  dilatation  of 

urethra,  448 
on  laceration  of  the  cervix,  204,  207, 

209 

on  pelvic  circulation,  48 
on  vesico-utero-vaginal  fistula,  479 
on  vesico- vaginal  fistula,  475 
Emmet  curette  forceps,  89 
Endocervicitis,  184 
definition  of,  165 
Endometritis,  a  cause  of  hemorrhage  at 

menopause,  618 
of  sterility,  150,  151 
acute  septic,  174 
acute  simple,  173 
anatomico-pathological  classification 

of  171 

atrophic,  171 
chronic  simple,  176 
decidual,  differentiated   from    mem- 
branous dysmenorrhea,  131 
definition  of,  165 
exfoliative.  172 
fungous.  171 
glandular,  171 
gonorrheal,  179 
acute,  ISO 
chronic,  182 
hyperplastic,  170 
hypertrophic,  170 
in  old  women,  183 
interstitial,  171 
not  preceded  by  an  acute  stage,  177 


INDEX 


635 


Endoraetritis,  polypoid,  172 
post-abortum,  176 
pseudodiphtheritic,  172 
senile,  183 
tuberculous,  173 

Endometrium,  anatomy  of,  166 
before  puberty,  168 
decidual  modification   of,   Fig.    146, 

352 

during  pregnancy,  169 
following  menopause,  169 
normal,  Fig.  65,  167 
pathology  of,  169 

Endoscopy,  direct,  110 

Enterocele  of  vagina,  371 

Enteroptosis,  67 

body  pose  in,  Fig.  19,  67 

Enuresis,  154 
in  children,  578 

Epilepsy,  incontinence  of  urine  in,  485 

Epispadias,  393,  445,  459 

Epstein  on  vulvo-vaginitis  in  children, 
566 

Erosion  of  cervix.     See  Cervix,  erosion 
of 

Escherich,    on     bladder    affections    in 
children,  579,  581 

Etiology  of  disease  in  any  organ.     See 
organ  affected 

Evacuator.  bladder,  Kelly,  Fig.  46,  102 

Examination,   positions  for.     See  Po- 
sitions 

Exanthemata,  menorrhagia  in,  135 

Excision  of  tissue  for  microscopic  ex- 
amination, 62 

Exploration  of  uterine  cavity,  digital, 
94 

External  genitals.     See    Genitals,  ex- 
ternal 

Extra-uterine    pregnancy.     See    Preg- 
nancy, extra-uterine 

Exudate,    pelvic.     See    Inflammation, 
pelvic 

FABKICIUS,  case  of  myoma  of  vagina, 
381 

Face,  aspect  of,  in  pregnancy,  420 
Facies  ovarina.  L)(.)4.  295.  302 
Fallopian    tube.     See  Tube.  Fallopian 
Familv  historv.     See    Historv.    familv 


Fecal  accumulation,  differential  diag- 
nosis of,  from  ovarian  tumor,  309 
Feces,  character  of,  as  a  symptom  of 

rectal  disease,  158 
incontinence  of,  in  children,  585 
Fen  wick,  E.  H.,  on  villus-covered  and 

bald  bladder  tumors,  481 
Ferguson  cylindrical  speculum,  86 
Fetus,  mummified,  345 
Fibro-cystic  tumors  of  uterus,  253 
Fibroids.     See  Uterus,  fibroids  of 
Fibroma.     See    Uterus,     fibroids    of; 

also  Ovary,  fibroma  of 
Fibromyoma  of  rectus  muscle,  310 
Figure,  the,  in  late  pregnancy,  426 
Fimbriated  extremity  of  tube,  Fig.  116, 

285 
Finger,  examining,  points  noted  by,  36, 

40 

introduction  of,  into  vagina,  35 
used  as  speculum,  36 
Fischel,  on    erosions  of   cervix  in  chil- 
dren, 563 

Fissure  in  ano,  503,  Fig.  194,  504 
diagnosis  of,  504 
differential  diagnosis  of,  505 
in  children,  585 
symptoms  of,  503 
syphilitic,  differentiated  from  fissure 

in  ano,  505 

Fistula,   between  bladder  and   extra- 
uterine  fetation  sac,  480 
between  bladder  and  ovarian  cyst, 

480 

between    bladder   and     pelvic    ab- 
scess, 480 
blind    internal    differentiated    from 

fissure  in  ano,  505 
entero-vaginal,  387 
in  ano,  516 

complete,  516,  Fig.  196,  517 
diagnosis  of,  518 
blind  external,  517 
blind  internal,  517,  Fig.  196a,  517 
symptoms  of,  518 
recto-vaginal,  386 
recto-vesical,  480 
uretero-intestinal,  493 
uretero-uterine,  492 
uretero-vaginal,  386,  492 


636 


INDEX 


Fistula,  uretero- vaginal,  differentiated 
from  vesico-vaginal  fistula,  478 
uretero- vesical,  492 
urethro- vaginal,  386 
vesico-intestinal,  479 
vesico-uterine,  479 

differentiated  from  vesico-vaginal 

fistula,  479 

vesico-utero-vaginal,  479 
vesico-vaginal,  384,  474 
diagnosis  of,  477 

frequency,    etiology,  and  pathol- 
ogy of,  474 
symptoms  of,  476 

Fistulas,  genital,  diagrammatic    repre- 
sentation of,  Fig.  189,  476 
scheme  of,  Fig.  155,  385 
ureteral,  492 
vesical,  474 

Flashes  or  flushes,  hot,  612 
Floor,  pelvic.     See  Pelvis,  floor  of 
Flowing.     See  Hemorrhage 
Forceps,  bladder,  alligator,  Fig.  50,  105 
Emmet  curette,  Fig.  30,  89 
rectal,  long  alligator,  Fig.  62,  125 
tenaculum,  double,  85 
uterine  dressing,  Fig.  23,  83 
vulsellum,  Fig.  25,  85 
Foreign    bodies    in    any    organ.     See 

organ  affected 
Fourchette,  Fig.  156,  389 
Fowler,   case  of  incontinence  of  feces 

in  a  girl  of  thirteen,  585 
Frankel,  function  of  the  corpus  luteum, 

13 

Friedlander,  C.,  doubtful  case  of  pri- 
mary tuberculosis  of  vagina,  365 

GAIT,  the,  in  late  pregnancy,  426 

C.alactocele,  539 

Garceau,  cases  of  primary  ureteral 
tumors,  493 

(lanv,  case  of  five  mamma?,  538 

Gartner's  duct,  cyst  of,  Fig.  154,  381 
diagram  of,  Fig.  120,  290 

Gautier,  V.,  cases  of  precociovis  men- 
struation and  precocious  maturity, 
564 

Gee,  on  hematuria  a  sign  of  infantile 
scurvy,  583 


Gellhorn,  G.,  on  development  of  hy- 
men, 396 

General  appearance,  in  case  records,  8 
General  health,  in  case  records,  8 
General    paralysis,    retention    and    in- 
continence of  urine  in,  485 
Genital  fold,  Fig.  157,  392 
Genital  hemorrhage  in  the  child,  571 
Genital  organs,  development  of,  Figs. 

158-162,  395 
external,     at     beginning    of     third 

month,  Fig.  157,  392 
atrophic  changes  in,  at  menopause, 

595 

development  of,  392 
inspection  of,  33 
Genital  ridge,  Fig.  157,  392 
Gierke,  cases  of  cystitis  with  yellowish 

plaques,  471 

on  noma  of  the  vulva,  570 
Girls,  little,  vulvar  hemorrhages  in,  572 

young,  examination  of,  25 
Glands,   Bartholin's,   abscess   of,   409, 

Fig.  176,  411 

abscess  of  ducts  of,  Fig.  175,  410 
anatomy  of,  391 
cancer  of,  414 

collection  of  discharges  from,  61 
cyst  of  left,  Fig.  174,  409 
cysts  of,  408 

differentiated    from    enterocele, 

371 

from  hernia,  413 
differential  diagnosis  of  cyst  and 

abscess  of,  412 

lurking-places  for  infection,  180 
Lushka's  coccygeal,  159 
lymphatic,  of  breast,  533 

enlarged  in  cancer,  553 
mammary.     See  Breast 
Skene's,  anatomy  of,  101 

collection  of  discharges  from,  61 
lurking-places  for  infection,  180 
thyroid,  function  of,  593 
Gonococcus,  characteristics  of,  179 
in  cervical  canal  in  children,  577 
infection,  179 

Gonorrhea,  179.  See  also  organ  affected 
history  of,  caution  in  procuring,  183 
latent,  in  women,  182 


INDEX 


637 


Gonorrhea,   latent,   lurking-places  for 

gonococcus  in,  452 

Goodsall  and  Miles,  analysis  of  symp- 
tom of  cancer  of  rectum,  527 
enumeration    of    abscesses  in   anal 

region,  515 
on   fistulae   originating   posterior   to 

anus,  518 
Graafian     follicles,  degenerated    after 

infectious  diseases,  577 
enlarged,  290 

Graves  bivalve  speculum,  Fig.  27,  87 
Gross,  S.  D.,  statistics  of  sarcoma  of 

breast,  551 
Growth,  failure  of,  a  cause  of  amen- 

orrhea,  139 

Gumma.     See  organ  affected 
Gusserow,    fatty  degeneration  of    fi- 
broids, 253 
percentages  of  ages  at  which  fibroids 

occur,  249 

Guyon,  observations  on  closure  of  os 
uteri  in  old  age,  624 

HAND,  examining,  showing  protective 

sleeve,  Fig.  2,  31 

Hanks  uterine  dilator,  Fig.  33,  91 
Hann,  R.  G.,  case  of  late  child-bearing, 

603 
case  of  recurrence  of  sexual  feeling  at 

forty-nine,  614 
Hare,   F.,  case   of  inhalation  of  amyl 

nitrite  stopping  menstruation,  596 
Hart   and   Barbour,    views   on    pelvic 

floor,  220 
Heart  disease,  a  Cause  of  hemorrhoids, 

500 

of  pelvic  congestion,  467 
menorrhagia  in,  135 
Heart  sounds,  fetal,  auscultation  of,  429 
Hegar,  view   that   tubes,   uterus,   and 
vagina  form  a  duct  for  the  gland,  the 
ovary,  593 
Hegar 's  sign,  425 

bimanual  palpation  for.  Fig.  179,  425 
Hematocele.  pelvic.  Fig.  142.  343,  347 
differentiated  from  pelvic  cellulitis, 

196 

Hematocolpos,  Fig.  171,  360 
Hematoma  of  ovary,  346 


Hematoma  of  vagina,  377 

of  vulva,  400 

Hematometra,  360,  Fig.  172,  398 
Hematosalpinx,    334,    360,   Fig.    139, 

335 

danger  of  rupturing,  398 
diagram  of,  Fig.  173,  399 
differentiated  from  small  ovarian 

tumor,  298 
Hematuria,    a    sign    of    papilloma    of 

bladder,  483 

a  symptom  of  ureteral  tumors,  493 
in  children,  583 
Hemophilia,  in  children,  571 

menorrhagia  in,  135 
Hemorrhage,  at  menopause,  617 

of  unexplained  causation,  619 
following  curetting,  94 
from  anus,  in  hemorrhoids,  502 
genital,  in  the  child,  571 
in  fibroid  tumors,  260 
uterine.     See  Menorrhagia  and  Met- 

rorrhagia 

Hemorrhoids  (or  piles),  498 
external,  500 

inflamed,  with  erosion,  Fig.   193, 

499 
not   to  be  pushed   into  anus  or 

squeezed,  501 

frequency  and  etiology  of,  498 
internal,  501 

hemorrhage  as  a  symptom  of,  157, 

502 

prolapsed,  Fig.  193,  499 
with  edema  of  anal  margin,  Fig. 

193,  499 

mucoid  discharge  in,  502 
thrombotic,  Fig.  193,  499 
types  of,  Fig.  193,  499 
Hermaphroditism,  399 
false,  female,  400 

male,  400 
true,  399 

Hernia,  anterior,  into  vagina,  368 
inguinal,  in  labium  majus,  412 

differentiated  from  rectocele,  371 
intestinal,  into  vagina,  differentiated 

from  cystocele,  368 
labial.  412 

in  the  child,  558 


638 


INDEX 


Hernia,     vulvar,    differentiated     from 

rectocele,  371 
Heubner,  on  masturbation,  575 

on  vulvo-vaginitis  in  children,  567 
Hilton's  white  line,  Fig.  191,  495 
Hind-gut,  arrested  development  of,  496 

development  of,  Fig.  158,  395 
Hirst,   B.   C.,   cases   of   operations   on 
pregnant  women  by  mistake,  418 

cases  of  ovarian  tumor  in  upper  ab- 
domen, 302 
History,  family,  7,  12 

method  of  getting,  5 

previous,  7,  12 

Hitschmann  and  Adler's  views  on  en- 
dometritis  hypertrophica,  171 

on  the  endometrium,  168 
Holt,  L.  Emmett,  on  masturbation.  575 

on  vulvo-vaginitis  in  children,  567 
Horizontal  section   of  uterus,  Fig.  67, 

171 

Hot  flashes  in  menopause,  612 
"  Hottentot  apron,"  394 
Hours,  P.,  on  metrorrhagia  of  puberty, 

573 

Houston,  valves  of,  122 
Huguier,     case    of    true    hypertrophic 
elongation  of  cervix,  225 

cases  of  abscess  of  duct  of  Bartho- 

lin's  gland,  410 

Hunner,  G.,  technique  of  finding  tu- 
bercle bacilli  in  urine,  469 
Hunter  vaginal  depressor,  89 
Hurdon,    E.,    cases    of    papilloma    of 
Fallopian  tube,  337 

views  on  sarcoma  of  uterus,  278 
Hiisler,  G.,  on  primary  tumors  of  blad- 
der in  children,  582 
Hydatid  disease.     See  Echinococcus 
"Hydatid  fremitus,"  299 
Hydatid  of  Morgagni,  327 
Hydatidiform  mole,  441,  Fig.  182,  442 

diagnosis  of,  443 

pathology  of,  441 

symptoms  of,  443 
Hydrocele  of  canal  of  Nuck,  213 
Hydrosalpinx,  333,  Fig.  13S,  334 

differentiated     from     small     ovarian 
tumor,  298 

follicular.  334 


Hydrosalpinx,  intermittent,  334 

Hydrup-Pederson,  case  of  atresia  of 
vagina  in  child  following  diphtheria, 
569 

Hymen,  Fig.  156,  389 
anatomy  of,  390 
atresia  of,  a  cause  of   amenorrhea, 

140 

development  of,  Fig,  162,  395 
different  forms  of,  Figs.  163-170,  397 
imperforate,  396 

in  the  child,  560 
malformations  of,  396 
rigid,  a  cause  of  sterility,  150 
with  pin- head  opening,  396 

Hyperemesis  gravidarum,  434 

Hypernephroma  differentiated  from 
ovarian  tumor,  313 

Hypophysis  cerebri,  tumors  of,  at- 
tended by  amenorrhea,  419 

Hypospadias,  393,  444 

Hysteria,  anuria  in,  156 
polyuria  in,  485 

ILLNESS,  present,  in  clinical  history,  22 
Imperforate  anus,  497 

rectum,  496 

Inbreeding,  a  cause  of  sterility,  151 
Incarceration  of  ovarian  tumors,  315 
Incontinence  of  feces  in  children,  585 

of  urine,  154,  485 

Infancy,  gynecological  affections  of,  555 
Infant  at  birth,  uterine  organs  of,  seen 

from  above,  Fig.  205,  562 
Infantile  uterus,  140,  202,  Fig.  117,286 

vulva,  Fig.  203,  556 
Infectious  diseases,  menorrhagia  in,  135 
Inflammation,  pelvic,  187 
a  cause  of  cystitis,  467 
causing  fixation  of  uterus  in  pro- 
lapse, 223 

differential  diagnosis  of  (table), 195 
dysmenorrhea  in,  129 
exudate     in,    differentiated     from 

cancer,  277 
from  fibroid,  263 
routes  of  infection  in,  187 
Injuries   of.      See  Vulva.  Vagina,  ITre- 

thra.  Bladder,  injuries  of 
Insemination  without  penetration,  149 


INDEX 


639 


Introitus  vaginae,  Fig.  156,  389 
Instruments,  care  of,  before  and  after 
use,  30 

for  examination,  list  of,  28 

in  diagnosis,  77 

Intercourse,   sexual.     See  Coitus 
Intermenstrual  pain,  132 
Intestines,    gas    or    fecal    matter    in, 

differentiated    from    large    ovarian 

tumor,  309 
Intra-abdominal    pressure,    variations 

in,  224 
Irrigator,     uterine,     Bozeman-Fritsch, 

Fig.  35,  92 

Irritable  bladder,  485 
Ischuria,  155 
Isthmus  of    Fallopian  tube,  Fig.  116, 

285  ' 
Itching.     See  Pruritus 

at  anus  after  going  to  bed,  a  symptom 
of  piles  or  eczema,  157 

of  vulva,  1GO 

JACOBI,    M.    P.,    on  menstrual    wave 

theory,  595 
Jacquemin's  sign,  422 
Jaundice,  menorrhagia  in,  135 
Jet  of  urine  from  ureteral  orifice,  Fig. 

52. 107 
Johnson,  F.  W.,  case  of  fibromyoma  of 

rectus,  310 
Jung,  on  gonococcus  in  cervical  canal 

in  children.  577 

KAKELS,  S.  W.,  on  vulvo-vaginitis  in 

children,  507 

Kehrer,  E.,  cases  of  pregnancy  in  rudi- 
mentary cornua. 433 
Kelly    and    Cullen.    on    myomata    of 

uterus.  249,  25*.  2(51 
on  myoma  of  vagina.  3S1 
Kelly.  H.  A.,  case  of  fibroid  that  had 
developed    while    under    observa- 
tion. 251 
cases  of  imperforate  hymen  following 

typhoid  fever,  .">(>() 

method   of  injecting  kidney   to  pro- 
duce renal  colic.  312 
pus    cells    in    urine    of    cystitis    con- 
verted   into  mucus   in  presence  of 
protons  infection,  472 


Kelly  cystoscope,  Fig.  49,  104 

double-ended    urethra!  dilator,  Fig. 

45,  102 

evacuator,  Fig.  46,  102 
meatus  calibrator,  Fig.  44,  101 
ureteral  catheter,  Fig.  48,  103 
ureteral  searcher,  Fig.  47,  102 
wash-bottle  suction  apparatus  in  use, 

Fig.  55, 113 

Kennedy,  W.  J.,  case  of  late   child- 
bearing,  602 

Kerley,  on  causes  of  enuresis,  579 
Kidney,  ache  in,  a  sign  of  papilloma  of 

bladder,  483 
echinococcus  cyst    of,  differentiated 

from  ovarian  tumor,  313 
movable,  differentiated  from  ovarian 

tumor,  313 
palpation  of,  70,  71 
polycystic  disease  of,  differentiated 

from  ovarian  tumor,  313 
simple  cysts  of,  differentiated  from 

ovarian  tumor,  313 
tumors  of,  differentiated  from  ova- 
rian tumor,  313 

Kisch,    cases  of  prolonged  menstrua- 
tion, 603 
table     of     gynecological     affections 

found  during  menopause,  589 
Knee-chest  position,  56,  Fig.  13,  56 
modified  for  cystoscopy,  Fig.  53,  111 
side  view  of,  Fig.  14,  57 
Kobelt's  tubules,  diagram  of,  Fig.  120, 

290 

Kraurosis  vulvae,  404 
Krieger,  E.,  statistics  as  to  age  of  the 
menopause,  597 

LABIA  MAJORA,  anatomy  of,  388 
malformations  of,  394 

Labia  minora,  adherent,  394 

anatomy  of,  390 

cysts  of,  413 

malformations  of,  394 
Labium  majus,  Fig.  156,  389 

hematoma  of,  400 

hydrocele  of,  in  the  child,  559 

tumor  of.  differentiated  from  entero- 

cele,  371 
from  hernia,  413 


INDEX 


Labium  minus,  Fig.  156,  389 
Labor,  premature,  definition  of,  436 
Laceration     of     cervix.     See     Cervix, 

laceration  of 

Laceration     of    perineum.     See    Peri- 
neum, laceration  of 
Lactation,  a  cause  of  amenorrhea,  141 

prolonged   amenorrhea    a   symptom 

in,  419 

Lactation  atrophy  of  uterus,  203 
Lactation  hypertrophy.     (See  Breast) 
Latent  gonorrhea,  182 
Latent  seedling  fibroids,  251 
Leg  holders,  57 

Leopold,  on  erosion  of  cervix  in  chil- 
dren, 563 
Levicorrhea,  143,  355 

a  cause  of  pruritus,  160 

a  symptom  of  endocervicitis,  185 
of  endometritis,  177 
of  pregnancy,  420 

bloody  discharge  in,  144 

"currant    juice,"    in    hydatidiform 
mole,  443 

fetid  discharge  in,  144 

in  case  records,  7 

in  children,  144 

in  clinical  history,  18 

in  fibroid  tumors,  261 

in  married  women,  145 

in  old  women,  146 

in  virgins,  145 

normal  vaginal  discharge  and,  355 

watery  discharge  in,  144 

white  discharge  in,  143 

yellow  discharge  in,  143 
Leukemia,  menorrhagia  in,  135 
Levator  ani  muscle.  Fig.  150,  373,  Fig. 

151,  374,  Fig.  152,  375 
Ligament,  infundibulo-pelvic,  Fig.  116, 
285 

of  ovary,  Fig.  116,  285 
Ligaments,  broad,  attachments  of,  44 
diseases  of,  211 
varicocele  of,  212 

round,  attachments  of,  45 
diseases  of,  212 
hydrocele  of,  213 
tumors  of,  212 

uterine,  anatomy  of,  44 


Ligaments,  uterine,  diseases  of,  210 

mechanics  of,  222 
utero-ovarian,  214 
utero-sacral,  213 
attachments  of,  44 
course     of,     in     intraligamentous 

tumor,  Fig.  135,  317 
in    retroperitoneal    tumor,   Fig. 

134, 316 

Light  for  cystoscopy,  varieties  of,   111 
Linea  alba,  pigmentation  of,  67,  427 
Linea  nigra,  67,  427 
Line*  albicantes,  67 
Lithopedion,  345 
Lithotomy  position,  57 
Liver,  cirrhosis  of,  a  cause  of  pelvic 

congestion,  467 
tumors  of,  differential  diagnosis  of, 

from  ovarian  tumors,  312 
Locomotor     ataxia,     incontinence     of 

urine  in,  155,  485 
Long  female  catheter,  Fig.  43,  101 
Lubricant  for  vaginal  examination,  35 
Lund,    F.    B.,    ovariotomy   on   three- 
months-old  child,  294 
Luys  urine  separator,  Fig.  59,  119 

McBuRNEY's  POINT,  337 

McCosh,  A.  J.,  case  of  early  carcinoma 

of  breast,  550 

McDonald,    E.,    on    rhythmical    con- 
tractions of  pregnant  uterus,  424 
Macula  gonorrhoica,  411 
Mamma.     See  Breast 
Marchand,  F.,  on  chorioepithelioma,  280 
on  pathology  of  hydatidiform  mole, 
541 
Mastitis,  acute,  542 

carcinomatous,  543 
chronic,  543 

actinomycotic,  544 
interstitial,  543 
lobular,  543 
syphilitic,  544 
tuberculous.  543 
Mastodynia,  553,  539 
Masturbation.  574 

a  cause  of  leucorrhea,  144 
of  sterility.  151 
of  vaginismus,  379 


INDEX 


641 


Masturbation,  and  pruritus,  161 

breast   changes  in,  similar  to  preg- 
nancy, 421 

Maturity,  precocious,  564 
case  of,  Fig.  207,  565 
Meatus  calibrator,  Kelly's,  Fig.  44,  101 
Meatus  urinarius,  Fig.  156,  389 
Memory,  loss  of,  in  menopause,  613 
Menopause,  587 

age  of  occurrence  of,  597 

atrophic  changes  in,  17 

blood  pressure  in,  613 

delayed,  601 

delusional  insanity  in,  615 

displacements  of  uterus  at,  620 

dodging  time  of,  611 

duration  of,  611 

dyspepsia  in,  615 

eczema  vulvse  at,  621 

gastritis,  atonic,  in,  615 

gastro-enteritis  in,  616 

hemorrhages  of,  617 

heredity  as  affecting,  598 

high  arterial  tension  in,  613 

hot  flashes  in,  612 

hyperchlorhydria  in,  615 

in  clinical  history,  16 

influence  of  race  and  locality  on,  597 

injuries  of  vagina  after,  621 

insomnia  in,  613 

intercostal  neuralgia  in,  663 

irritability  of  temper  in,  613 

loss  of  memory  in,  613 

melancholia  in,  615 

mental  diseases  at,  615 

nervous  system  in,  613 

neurasthenia  in,  614 

nut-'          in.  616 

obesity  at,  616 

phenomena  of  body  and  mind  in.  612 

premature.  598 

associated  with  obesity,  599 

pruritus  vulva?  at,  161,  621 

psychoses  in,  615 

pulse  rate  in,  613 

rheumatism  in,  616 

sexual  feeling  in.  614 

skin  diseases  in.  617 

tables  of  115  cases  of,  604 

tachycardia  in.  613 


Menopause,  vesical  symptoms  at,  621 
Menorrhagia,  134 

constitutional  causes  of,  135 

differentiation  of,  from  abortion,  441 
Menorrhagia  and  metrorrhagia,  differ- 
entiated from  abortion,  441 

in  married  women,  139 

in  nulliparse,  137 

in  parous  women,  138 

in  pregnancy,  138 

in  virgins,  137 

local  causes  of,  135 
Menstrual  period,  a  predisposing  cause 

of  cystitis,  467 

Menstruation,    date    of    beginning   of 
last,  8 

delayed,  and  pelvic  disease,  15 

description  of,  13 

during  pregnancy,  419 

in  case  record,  7 

molimen  of,  128 

physiology  of,  595 

precocious,  564 

prolonged,  603 

vital  energy,  wave  of,  governing,  595 

wave  theory  concerning,  595 
Mensuration  of  abdomen,  74 
Mental  disease  at  menopause,  615 

overwork,  a  cause  of  amenorrhea,  142 
Metritis,  165 

chronic,  a  cause  of  hemorrhage  at 

menopause,  618 
Metrorrhagia,  134 

after  menopause  a  sign  of  cancer,  138 

coming  on  six  weeks  after  labor  may 
mean  chorioepithelioma,  138 

differentiated  from  abortion,  441 

may  mean  extra-uterine  pregnancy, 
138 

may  mean  uterine  polyp,  138 
Michaelis'  rhomboid,  96 
Micturition,  frequent,  153 

a  symptom  of  pregnancy,  420 

painful,  151 

"Milk  line,"  532,  Fig.  200,  538 
Miscarriage,  definition  of,  436 

diagnosis  of,  440 
Miscarriages  and  abortions,  in  clinical 

history,  11 
Mittelschmerz,  132 


642 


INDEX 


Mole,  hydatidiform,  in  Fallopian  tube, 
345 

tubal,  344 

Molimina,  menstrual,  128 
Mons  veneris.  Fig.  156,  389 

anatomy  of,  388 

Morgagni,  columns   of,    123,  Fig.  191, 
495 

crypts  of,  123,  Fig.  191,  495 

hydatid  of,  327 

valves  of,  123,  Fig.  191,  495 
"Morris'  points,"  337 
Morse,  J.  L.,  cases  of  precocious  men- 
struation and  precocious  maturity, 
564 

on  bacteriuria,  579 

on  hematuria  in  scurvy,  583 
Mucous  patches.     See  Vulva  and  Anus 
Miiller's  ducts,  197.  Fig.  71,  198 
Multiple  sclerosis,  retention  of  urine  in, 

485 
Muscular  rheumatism,  19 

of  pectoralis  major,  553 
Myoma.     See  Uterus,  fibroids  of 
Myoma    and    cancer    to    be    excluded 

from  statistics  on  menopause,  590 

NABOTHIAN  FOLLICLES,  cysts  of,  41, 185 
Nationality,  in  clinical  history.  9 
Nausea    and    vomiting,   symptoms    of 

pregnancy,  419 
Neisser,  gonococcus  of,  179 
Nephritis,  acute,  anuria  in,  156 
Neugebauer,  on  hermaphroditism,  399 
Neugebauer  bivalve  speculum,  86 
Neumann,  F.,  cases  of  joint  disease  at 

menopause,  616 

Neuralgia,  intercostal,   in  menopause, 
613 

mammary,  539,  553 
Neurasthenia  and  dysmenorrhea,  130 
Neurasthenia    associated    with    coccy- 

godynia.  159 
New-bom,  the,  genital  hemorrhages  in, 

571 
Nipple,  anatomy  of,  532 

discharge  from,  in  late  cancer,  553 

discharge  of  blood  from,  545,  546 

Paget's  disease  of,  548 

retraction  of,  553 


Nitze  cystoscope,  Fig.  56,  116 

Noble,  C.  P.,  case  of  recto-vesical  fistula, 

480 

views  on  fibroids,  246,  253,  255,  256 
Nuck,  canal  of,  hydrocele  of,  213 

differentiated  from  cyst  or  ab- 
scess of  labium,  412 
from  hernia,  413 
Nymphse,  adherent,  394 
anatomy  of,  390 
hypertrophy  of,  394 

OBESITY,  amenorrhea  a  symptom  in, 

141,419 

associated    with    premature    meno- 
pause, 599 
at  menopause,  616 
rapidly  occurring,  a  cause  of  sterility, 

151 

Occupation,  in  clinical  history,  9 
Odor  as  a  diagnostic  sign,  60 
Old  age,  622 

conventional  time  for  the  beginning 

of,  588 
Olshausen,  views  on  sterility  in  fibroid 

tumors,  258 
Omentum,  cyst  of,  differentiated  from 

ovarian  tumor,  313 

Oophoron,  atrophied  because  of  pres- 
sure, 290 

diagram  of,  Fig.  120,  290 
Os,  parous,  Fig.  66a.  169 

virginal.  Fig.  66,  168 
Os  tincae,  41 

Ostheimer  and  Levi  on  enuresis,  579 
Ostium  abdominale  of  tube,  Fig.  116, 

285 
Ovaritis.  288 

acute,  diagnosis  of,  288 
chronic,  290 

diagnosis  of,  290 
differentiation  of,  from  small  ovarian 

tumor,  297 
Ovary,   adhesions   about,    a   cause   of 

sterility,  150 

anatomy  and  age  changes  of.  284,  592 
and  tube  seen  from  behind.  Fig.  116, 

285 

anomalies  of.  285 
atrophic  changes  of.  in  old  age.  62'-? 


INDEX 


643 


Ovary,  atrophy  of,  285 

a  cause  of  amenorrhea,  141 

of  sterility,  150 

following  steaming  of  uterine  cav- 
ity, 286 

in  exanthemata,  285,  599 
lactation.  285 
cancer  of,  primary,  322 
changes  in,  at  menopause,  592 
corpus  luteum  of,  cysts  of,  321,  for- 
mation of,    592 
function  of,  13 
cyst  and  tumor  of,  regions  of,  Fig. 

120,  290 

cyst  of.     See  Ovary,  tumors  of,  va- 
rieties of:  cysts 
large,  differentiated  from  ascites, 

308 

from  large  fibroid,  309 
showing  emaciation  and  "  facies 
ovarina,"  Fig.   125,  294 
degeneration     of,     parenchymatous, 

599 

small  cystic,  290 

development  of,  Fig.  71,  198,  592 
diseases  of,  284 

in  the  child,  576 
displacements  of,  286 
fibroma    of,  differentiated  from    pe- 

dunculated  fibroid,  263 
function  of,  592 

impaired    by    infectious    diseases, 

577 
(Jraafian  follicles  of,  degeneration  of, 

after  infectious  diseases,  577 
hernia  of,  288 
infantile,  Fig.  117,286 
inflammation  of,  288 
normal,  palpation  of,  41 

position  of,  48 

of  mature  woman,  Fig.  118,  287 
prolapse  of,  286 
sclerosis  of,  in  tuberculosis,  599 
senile.  Fig.  119,  289 
small  cystic  degeneration  of,  290 
tumors  of,  291 

a  cause  of  .sterility,  150 
aspiration  of,  305 
association     of,    with    pregnancy, 
320 


Ovary,  tumors  of,  classification  of,  293 
complications  of,  315 
cross  section  of  body  in,  Fig.  127, 

302 

degenerative  processes  in,  319 
diagnosis  of,  in  general,  295 

in  the  child,  577 

differential  diagnosis  of  pathologi- 
cal varieties  of,  321 
etiology  and  symptoms  of,  293 
Hegar's    method    of    determining 
relation  of,  to  uterus,  Fig.  126, 
301 

in  old  age,  623 
infantile,  Fig.  206,  262 
infection  of,  318 
intraligamentous  development  of, 

316 
large,  diagnosis  of,  301 

differential  diagnosis  of,  305 
differentiated  from  cyst  of  pan- 
creas, 311 

from  cysts  of  omentum,  313 
from  dilated  stomach,  314 
from  distended  bladder,  314 
from  echinococcus  cysts,  314 
from  fat  in  abdominal  walls, 

310 

from  fecal  accumulation,  309 
from  fibroids,  309 
from  pregnancy,  305 
from  tumors  of  spleen,  liver, 

and  kidneys,  312 
inspection  of,  302 
palpation  of,  302 
percussion  of,  303 
malignancy  of,  293 
modes  of  development  of,  292 
pedicle   formation  of,  Figs.    121- 

124,  292 
pedicle  of,  pain  caused  by  traction 

on, 296 

palpation  of,  295 
torsion  of,  317 
rupture  of,  319 
small,  diagnosis  of,  297 

differential  diagnosis  of,  297 
differentiated     from     distended 

bladder,  300 
from  echinococcus    cyst,  299 


644 


INDEX 


Ovary,  tumors  of,  small,  differentiated 
from    encapsulated    peritoni- 
tis, 298 
from  extra-uterine  pregnancy, 

299 

from  ovaritis,  297 
from  parovarian  cyst,  298 
from  pregnancy,  300 
from     suhperitoneal     fibroid, 

297 

from  tumors  of  the  tube,  298 
suppuration  of,  318 
symptoms  of,  294 
tapping  of,  305 
varieties  of: 

adhesions  and  incarceration,  315 
carcinoma,  primary,  322 
cysts,  dermoid,  322 

differentiation  of,  from  fibroid, 

262 

follicular,  321 
multilocular,  321 
proliferating,  321 
simple,  321 
endothelioma,  323 
fibroma,  322 

differentiation  of,  from  fibroid 

of  uterus,  263 
perithelioma,  323 
sarcoma,  322 
teratomata,  322 
undescended,  286 
Ovulation,  prolonged,  603 
Ovum,  growth  of,  in  early  pregnancy, 

423 

Oxyuris  vermicularis,  a  cause  of  pruri- 
tus, 161 

PAGET'S  DISEASE  of  the  nipple,  548 
Pain  following  defecation,  a  symptom 
of  fissure  or  fistula,  157 

in  anus,  after  going  to  bod.  a  symp- 
tom of  piles  or  ec/ema,  157 

in  case  records,  7 

in  clinical  history,  IS 

in   course   of  ureter,  a  symptom   of 
stricture,  489 

in  fibroid  tumors.  2(>l 

in    groins,    in    clinical    history,     19 

intermenstrual,  132 


Pain,  menstrual.     See  Dysmenorrhea 
Palpation,  bimanual,  diagram  of,  Fig. 

5,  38 

for  Hegar's  sign,  Fig.  179,  425 
structures  to  be  felt  by,  49 

in  diagnosis,  34 

pelvic  structures  felt  by,  40 
Palpitation  in  fibroids,  259 

in  menopause,  613 
Pancreas,  cyst  of,  differentiated  from 

large  ovarian  tumor,  311 
Paralysis,  a  cause  of  cystitis,  467 
Paravaginitis,  362 

phlegmonosa  dissecans,  362 
Parkinson,  J.  P.,  on  hematuria,  a  sign 

of  infantile  scurvy,  583 
Paroophoron,    diagram    of,    Fig.    120, 

290 

Parovarium,  cyst  of,  211 
contents  of,  211 
differentiated  from  small  ovarian 

tumor,  298 

large  cyst  seen  in  profile,  Fig.  128, 
303 

diagram  of,  Fig.  116,  285,  290 
Pathology    of   disease    in  any    organ. 

See  organ  affected 

Patient,  preparation  of,  for  examina- 
tion, 23 
Pectoralis  major  muscle,   rheumatism 

of,  553 
Pedicle,    See  Ovary,  tumor  of,  pedicle 

torsion  of,  317 
Pediculus  pubis,  a  cause  of  pruritus, 

161 

Pelvic  abscess,  193 

Pelvic    cellulitis,    192.     See   also   Cel- 
lulitis,  pelvic 

definition  of,  187 
Pelvic  congestion ,  a  cause  of  leucorrhea, 

145 
Pelvic    inflammation,    187.     See    also 

Inflammation,  pelvic 
Pelvic  organs  of  an  infant  at  birth,  seen 

from  above,  Fig.  206,  562 
Pelvic  peritonitis,  188.     See  also  Peri- 
tonitis, pelvic 

definition  of.   187 

Pelvimeter,  Collyer's,  Fig.  42,  98 
Pelvnnetrv,  95 


INDEX 


645 


Pelvis,    abdomen    and      contents    of, 

mechanics  of,  44 
cancer  of,  differentiated  from  fibroid, 

263 

cavity  of,  estimating  of,  98 
circulation  of,  46 
contents  of,  anatomy  of,  43 

from  above,  Fig.  9,  48 
deformities  of,  95,  96 
diameter     of,     conjugate,     Baude- 

locque's,  96 
external  conjugate,  96 
oblique  conjugate,  97 
oblique  diagonal,  98 
transverse,  98 
dimensions  of,  95 
female  normal,  Fig.  9a,  50 

showing  accessibility  of  contents 

to  palpation,  Fig.  10,  52 
with  hand  in  position  for  vaginal 

examination,  Fig.  4,  37 
floor  of,  diagram  showing  structures 

of,  Fig.  150,  373. 

injuries  of.     See    Perineum,  inju- 
ries of 

lacerations  of,  372 
mechanics  of,  221 

of  new-born  child,  longitudinal  me- 
dian section  of,  Fig.  204,  558 
outlet  of,  transverse  diameter  of,  98 
Penrose,  C.  B.,  on  erosion  of  cervix  in 

infants.  563 

Percussion  of  abdomen,  71 
Perineum  ("Perinea!  body"),  221 
development  of,  Figs.   160-161-162, 

395 
injuries  of,  a  cause  of  garrulity  of 

vagina.  378 
due  to  coitus,  376 
laceration  of,  372 

a  cause  of  sterility,  150 
complete.  374 

median.  Fig.  151,  374 
partial.  374 

lateral.  Fig.  152.  375 
through  the  sphincter  ani,  374 
Peristalsis,  waves  of,  seen  on  inspection 

of  abdomen,  66 
Peritoneum,  anatomy  of,  1SS 

folds  of,  reflections  of,  Fit:.  70,  IS!) 


Peritonitis,  body  pose  in,  67 

encapsulated,     differentiated     from 

small  ovarian  tumor,  298 
pelvic,  188 
acute,  190 
chronic,  191 

differential  diagnosis  of,  195 
etiology  of,  189 

in    Douglas'    cul-de-sac,    differen- 
tiated from  cellulitis,  195 
tuberculous,  191 
Pessaries,    a    cause    of    ulceration    of 

vagina,  377 
Pfannenstiel,  classification  of  ovarian 

tumors,  291 

Phantom,  bladder,  Fig.  58,  118 
"Phantom  tumor,"  311 
Phthisis,  menorrhagia  in,  135 
Physician,  preparation  of,  for  examina- 
tion, 31 

Piles.     See  Hemorrhoids 
Pincus,  L.,  views  as  to  atresia  of  vagina 

following  infectious  diseases,  560 
"Pinholeos,"41,81 
Pin-worms,  a  cause  of  pruritus,  161 
Placing  patient  on  table,  33 
Poisonings,  anuria  in,  156 
chronic,  amenorrhea  a  symptom  in, 

419 

menorrhagia  in,  135 
Polypus  and  polypi.    See  Endometritis, 
Uterus,    fibroids    of,    Urethra,  and 
Rectum 
Position,  dorsal,  33 

for  examination,  Fig.  3,  32 
knee-chest,  Fig.  13,  56 

modified  for  cystoscopy,  Fig.  53, 

111 

side  view,  Fig.  14,  57 
lithotomy,  Fig.  15,  58 
raised  pelvis.  Fig.  16,  59 
Sims,  Fig.  11,53 

diagram  of,  Fig.  12,  54 
standing,  Fig.  17,  60 
Pott's    disease,    retention    and    incon- 
tinence of  urine  in,  485 
Poxzi,  S.,  on  development  of  hymen, 

396 

Precocious    maturity,  a  case    of,  Fig. 
207,  565 


646 


INDEX 


Pregnancy,  a  cause  of  amenorrhea,  141 
a  cause  of  pelvic  congestion,  467 
abdominal,  340 

secondary,  345 
abnormal,  diagnosis  of,  432 
advanced,  a   cause   of    retention  of 

urine,  155 

associated  with  ovarian  tumor,  320 
breasts  in,  420,  421 
diagnosis  of,  417 

diagnosis  that  it  has  occurred  pre- 
viously, 433 

differential  diagnosis  of,  431 
differentiated    from    fibroid   tumor, 

264 

from  large  ovarian  tumor,  305 

from  small  ovarian  tumor,  300 

during  first  three  months,  diagnosis 

of,  418 
during  last  six  months,  diagnosis  of, 

426 

early,  bimanual  touch  in,  423 
extra-uterine,  340 

differentiated  from  abortion,  441 
from  normal  pregnancy,  431 
from  small  ovarian  tumor,  299 
early,  348 

ampullar,  Fig.  140,  341 

mole  and  fetus  removed  from 

tube  in,  Fig.  141,  342 
diagnosis  after  rupture,  351 
late,  350 

ampullar,  unruptured,  Fig.  145, 

350 

diagnosis  of,  353 

section  of  uterus,  showing  endome- 
trial  modification,  Fig.  146,  352 
symptoms  and  signs  of,  346 
in  bicornute  uterus,  433 
interstitial,  Fig.  144,  346 

diagnosis  of,  433 
menstruation  during,  419 
multiple,  diagnosis  of,  434 
nausea  and  vomiting,  symptoms  of, 

419 
normal,    differentiated    from    small 

ovarian  tumor,  300 
ovarian,  345 

pernicious  vomiting  of,  434 
salivation  in,  420 


Pregnancy,    symptoms   and   signs  of, 
table  of,  430 

tubal,  341 

diseases  of  ovum  in,  345 
fate  of  fetus  in,  344 
mole  formed  in,  344 

multiple,  348 

pathology  of,  343 

repeated,  348 

rupture  of,  344 

uterine  decidua  formed  in,  344 

tubo-abdominal,  340 

tubo-ovarian,  340 

tubo-uterine,  340 
Premature  labor,  definition  of,  436 

menopause,  598 
Prepuce,  Fig.  156,  389 

a  cause  of  enuresis,  558 

adherent,  394 

in  the  child,  557 
Present  illness,  in  case  records,  7 

in  clinical  history,  13,  22 

in  interpretation  of  clinical  history, 

22 

Previous  history,  7,  12 
Probe,  uterine,  Fig.  22,  82 
Procidentia,  Fig.  87,  223 
Procreation,  factors  essential  for,  149 
Proctitis,  505 

acute  catarrhal,  506 

atrophic,  507 

chronic  catarrhal,  507 

differentiation    of    atrophic    from 
hypertrophic,  509 

dysenteric,  513 

gonorrheal,  510 

hypertrophic,  508 

in  children,  585 

simple,  506 

specific,  510 
Proctodeum,  development  of,  Fig.  160, 

395 
Proctoscope,  long.  Fig.  61,  124 

short,  Fig.  60,  123 
Proctcscopy,  124 

Prolapse.     See  Uterus,  prolapse  of 
Pruritus  vulvir,  160,  404 
Pseudohermaphroditism,  400 
Pseudomasturbation,  574 
Puberty,  description  of,  14 


INDEX 


647 


Puberty,  metrorrhagia  of,  573 
Puerperium,  a  favorable  time  for  be- 
ginning of  retroversion,  235 
Purpura,  menorrhagia  in,  135 

in  the  child,  572 
Pyosalpinx,  332,  Fig.  137,  333 

differentiated  from   pelvic  cellulitis, 

196 

from  small  ovarian  tumor,  298 
rupture  of,  333 

RACHFORD,  B.  K.,  on  pseudomastur- 

bation,  574 

Raised  pelvis  position,  58 
Reconstruction  of  uterus,  Fig.  64,  166 
Rectal  speculum,  Sims,  Fig.  63,  126 
Rectal  symptoms,  156 
Recti  muscles,  separation  of,  66 
Rectocele,  369,  Fig.  149,  369 
at  menopause,  621 
diagram  of,  Fig.  149a,  370 
Rectum,  adenoma  of,  523 
anatomy  of,  121 
anomalies  of,  495 
cancer  of,  525 
diagnosis  of,  528 
differential  diagnosis  of,  528 
frequency  of,  525 
hemorrhage  as  a  symptom  of,  157 
pathology  and  course  of,  526 
symptoms  of,  527 
chancre  of,  512 
chancroids  of,  512 

development  of.  Figs.   158-162,  395 
digital  examination  of,  123 
discharge  from,  as  a  symptom,  157 
diseases  of.  494 

in  children,  584 

exudate  about  a  fistula  of,  differen- 
tiated from  cancer,  528 
fecal  accumulation  in,  as  a  symptom, 

157 

fibre-adenoma  of.  523 
fibroma  of,  524 
gununa  of,  .512 

differentiated  from  cancer.  529 
hemorrhage  from,  as  a  symptom.  157 
imperforate,  49(5.  5<>1 
inflammation     of.     505.     See     also 
Proctitis 


Rectum,  inspection  of,  124 
lower  part  of,  Fig.  195,  515 
lymphadenoma  of,  523 
new  growths  of,  522 
pain  in,  as  a  symptom,  156 
polyp  of,  differentiated  from  cancer, 
529 

fibrous,  524 

glandular,  524 

hemorrhage  as  a  symptom  of,  157 

mucous,  523 

myomatous,  524 

myxomatous,  525 
prolapse  of,  521 

complete,  522 

hemorrhage  as  a  symptom  of,  157 

in  children,  584 

incomplete,  522 
sarcoma  of,  529 
stricture  of,  518 

congenital,  519 

differentiated  from  cancer,  529 

due  to  pressure  from  without,  519 

inflammatory,  519 

spasmodic,  519 
syphilis  of,  510 
syphilitic  ulceration  of,  512 
tuberculosis  of,  513 
tuberculous   ulceration   of,   differen- 
tiated from  cancer,  528 
veins  of,  123 
villous  tumor  of,  524 

differentiated  from  cancer,  529 
Rectus  muscle,  fibromyoma  of,  310 
Reflections  of  folds  of  peritoneum,  Fig. 

70,  189 
Rheumatic     diathesis     and     pruritus 

vulva?,  161 

Rheumatism,  at  menopause,  616 
muscular,  19 

of  pectoralis  major,  553 
Richardson,  M.  H.,  on  evils  of  too  posi- 
tive    an     opinion     about    breast 

tumors,  549 
on  importance  of  making  a  complete 

physical  examination  in  the  case 

of  breast  tumors,  554 
Riviere,   A.,    case   of  incontinence   of 

feces  in  a  girl  of  nine,  586 
Robb  leg-holders,  57 


INDEX 


Rodman,  W.  L.,  analysis  of  5,000  cases 

of  cancer  of  the  breast,  551 
on  operability  of  cancer  of  the  breast, 

549 

on  the  three  most  important  points 
in    diagnosis    of    tumors    of    the 
breast,  550 
Rossi-Dor ia,  delayed  menstruation  and 

pelvic  disease,  15 
Round      ligaments.     See     Ligaments, 

round 

Rupture  of   ovarian  cyst  by  forcible 
manipulations,  319 

SACRO-ILIAC  SUBLUXATION,  18 
Sactosalpinx,  332 

diagnosis  of,  335 
Salpingitis,  327 

actinomycotic,  332 

acute,  327 

catarrhal,  327 

chronic,  329 

diagnosis  of,  328 

differentiated  from  appendicitis,  336 

echinococcic,  332 

follicular,  a  cause  of  sterility,  151 

gonorrheal,  330 

obliterating,  a  cause  of  sterility,  150 

purulent,  328 

symptoms  of,  328 

syphilitic,  332 

tuberculous,  330,  Fig.  136,  331 
Sampson,   J.   A.,   on   pain   caused   by 

twisting  pedicle  of  tumor,  296 
Sanger,  M.,  on  chorioepithelioma,  280 
Sapremia,  175 
Schulkowski,  on  genital  hemorrhage  in 

the  new-born,  572 
Sclerosis,  multiple,  retention  of  urine 

in,  485 
Scurvy,  hematuria  in,  583 

menorrhagia  in,  135 
Sea  voyages,  amenorrhea  following.  419 
Searcher,  ureteral,  Kelly,  Fig.  47,  102 
Searching  urethra  and  bladder,  10S 
Separator,  urine,  Luys,  Fig.  59,  119 
Sepsis.    See  Endometritis,  acute  septic 
Septicemia,  175 

Sexual  feeling  at  menopause,  614 
Sim  an  speculum,  86 


"  Simpson  symptom  "  of  cancer  of  body 

of  uterus,  276 
Sims  position,  54 

rectal  speculum,  Fig.  63,  126 
vaginal  speculum,  88 
Sinus,  urogenital,  persistence  of,  393, 

444 
urogenitalis,  Fig.  71,  198,  Fig.  157, 

392,  Fig.  160,  395 
Skene's  glands,  anatomy  of,  101 
collection  of  discharges  from,  61 
lurking-places  for  infection,  180 
Slanting  shelf  formed  by  psoas  muscles 

and  false  pelvis,  Fig.  86,  221 
Social  condition,  in  clinical  history,  10 
Souffle,  uterine,  429 
Sound,  uterine,  78,  Fig.  21,  78 
caution  in  use  of,  82 
facts  to  be  learned  by  use  of,  80 
how  to  pass  bimanually,  79 

by  sight,  80 
when  to  pass,  78 
Sound  touch,  81 
Spasm  of  bladder,  109,  465 
Speculum,  rectal,  Sims,  Fig.  63,  126 
uterine,  Burrage,  Fig.  36,  93 
vaginal,  85 
bivalve,  85 

Brewer,  Fig.  26,  87 
Edebohls,  86,  Fig.  32,  91 
Graves  bivalve,  Fig.  27,  87 
Sims,  87,  Fig.  28,  88. 
Speese,    John,    on    predisposition    to 
cancer  furnished  by  lactation  mas- 
titis, 544 
Sphincter   ani,   action    of,   preventing 

healing  of  fissure,  123 
external,  Fig.  195,  515 
hypertrophy  of,  in  hemorrhoids,  503 
internal,  Fig.  195,  515 
method  of  stretching  of,  126 
Spinal  cord,  disease  of,  a  cause  of  in- 
continence of  urine,  155 
Spirocha'ta  pallida,  in  chancre  of  vulva, 

407 

in  mucous  patches  of  vulva,  407 
Spleen,  tumors  of,  differentiated  from 

ovarian  tumors.  312 
wandering,  differentiated  from  ova- 
rian tumor,  312 


INDEX 


649 


Stammering  of  bladder,  109,  465 
Starfinger    on    sarcoma   of   vagina   in 

children,  382 

Stark,  M.  M.,  cases  of  premature  meno- 
pause, 600 
Stephenson,   W.,   on   menstrual  wave 

theory,  595 
Sterility,  147 

age  as  affecting,  148 

conditions    of    uterine    organs    that 
interrupt  pregnancy,  150 

constitutional  diseases  causing,  151 

due   to   anomalies   and   diseases   of 
uterine  organs,  150 

in  the  male,  148 
Stomach,  dilated,  differentiated   from 

ovarian  tumor,  314 
Stone  in  bladder,  462 

in  children,  582 
Storer,  M.,  cases  of  bilateral  torsion  of 

Fallopian  tubes,  336 
Straining,  a  cause  of  hemorrhoids,  500 

at  stool,  with  sense  of  only  partial 
relief,  a  symptom  of  stricture  of 
rectum,  158 
Strangury,  152 
Stricture     of     rectum.     See     Rectum, 

stricture  of 
Sub  in  volution.  207 
Sunstroke,  anuria  in,  156 
Swelling  of  feet  and  legs  in  fistula  in 

ano,  520 
Symptoms   of   disease    in    any   organ. 

See  organ  affected 
Syphilis.     See  organ  affected 

a  cause  of  abortion.  437 

a  cause  of  sterility,  151 

menorrhagia  in,  135 

TAHLE.  examining,  preparation  of,  26 
Tachycardia,  in  fibroids.  259 

in  menopause.  613 
Taylor,  case  of  late  conception,  603 
Tenaculum.  uterine.  Fig.  24.  S3 
Tenaculum  forceps,  double.  S5 
Thornton,     case     of     ovariotomy     on 

woman  ninety-four  years  old.  294 
Thyroid.      Sec  ("Hand 
Tilt.  E.  J.,  cases  of  prolonged  menstru- 
ation, 604 


Tilt,  table  of    comparative   dates    of 
cessation  of  menstruation  in  dif- 
ferent countries,  598 
table  of  uterine  diseases  found  during 

menopause,  589 

views  on  length  of  dodging  time,  611 
Tissue,  preservation  of,  63 

removal  of,  for  microscopic  exami- 
nation, 62 

Torsion  of  uterus,  244 
Touch,  bimanual,  diagram  of,  Fig.  5,  38 
hindrances  to,  39 
structures  to  be  felt  by,  49 
vagino-abdominal,  38 
rectal,  50 
recto-abdominal,  53 

in  examination  of  children,  556 
sound,  81 
vaginal,  34 
vagino-abdominal,  38 
Townsend,  C.  \V.,  on  incontinence  of 
urine  relieved  by  removal  of  rectal 
polyp,  579 

Treatment  advised,  in  case  records,  8 
Trigone,  hyperemia  of,  471 
Trigonitis,  471 
Tube,  Fallopian,  a  carrier  of  infection 

to  ovarian  tumors,  318 
absence  of,  326 
accessory,  326 
anatomy  of,  324 
anomalies  of,  326 
atrophic  changes  in,  in  old  age,  623 
atrophy  of,  at  menopause,  594 
carcinoma  of,  338 
chorioepithelioma  of,  339 
cyst  of  Morgagni  of,  327 
diseases  of,  324 

in  the  child,  576 
displacement  of,  326 
diverticula  from,  326 
elongation  of,  326 
embryoma  of,  338 
fibroma  of,  338 
fibromyxoma  of,  338 
function  of,  325 
hernia  of,  326 
infantile,  Fig.  206,  562 
inflammation  of,  327 
myoma  of,  338 


650 


INDEX 


Tube,  Fallopian,  new  growths  of,  337 
papilloma  of,  337 
polypus  of,  337 
retention  tumors  of,  332 

rupture  of,  336 
sarcoma  of,  339 
tumors     of,     differentiated     from 

small  ovarian  tumors,  298 
Tuberculosis.     See  organ  affected 

amenorrhea  a  symptom  in,  419 
Tubo-ovarian  cyst,  334 
Tumor    of     any     organ.     See     organ 

affected 

rising  from  pelvis,  outlined  by  ab- 
dominal walls,  66 

Turpentine,  a  cause  of  cystitis,  467 
Tuttle,  J.  P.,  on  frequency  of  cancer  of 

rectum,  525 
Typhoid  fever,  anuria  in,  156 

UNDEKHILL,  F.  P.,  and  Rand,  R.  F., 

on  the   urine  in  pernicious  vomiting 

of  pregnancy,  436 
Urachus,   cyst   of,   differentiated  from 

ovarian  tumor,  311 
Uremia,  anuria  in,  156 

menorrhagia  in,  135 
Ureter,  absence  of,  486 

anatomy  of,  103 

anomalies  of,  486 

blood  clot  in,  a  cause  of  stricture,  489 

calculus  of,  .490 

cancer  of,  a  cavise  of  stricture,  489 

catheterization  of,  115 

compression  of,  by  fibroid,  257 

development  of,  Fig.  71,  198 

diseases  of,  486 
•  double,  486 

echinococcus  cyst  in,  a  cause  of  stric- 
ture, 489 

fistula?  of,  492 

gumma  of,  a  cause  of  stricture,  489 

inflammation  of,  488 

mucosa  of,  prolapse  of,  491 

new  growths  of,  493 

occluded,  cystic  dilatation  of.  487 

orifice  of.     See  Bladder,  anatomy  of 
abnormal  situation  of,  486 
swollen,  488 
urine  spurting  from.  Fig.  52,  107 


Ureter,  stone  in,  490 

a  cause  of  stricture,  489 

stricture  of,  489 

tumors  of,  493 

valve  formation  in,  489 
Ureteritis,  488    , 
Urethra,  anatomy  of,  100 

angioma  of,  453 

anomalies  of,  444 

atresia  of,  445 

bladder  and,  searching  of,  106 

bladder  and  ureters,  and,  examina- 
tion of,  107 

cancer  of,  455 

caruncle  of,  453,  Fig.  184,  454 
a  cause  of  dysuria,  152 
of  sterility,  150 
of  vaginismus,  379 
differentiated    from    cancer,    415, 

455 
from  prolapse  of  muscosa,  449 

development  of,  Fig.  71,  198, 
Figs.  160-162,  395 

dilated  and  short,  444 

dilatation  of,  447 
limits  to,  448 

diseases  of,  444 

dislocation  of,  downward,  109,  446 
upward,  445 

external,  partial  defect  of,  444 

fibroma  of,  455 

granuloma  of,  453 

inflammation  of,  450 

mucosa  of,  prolapse  of,  448 

mucous  membrane    of,  prolapse  of, 
Fig.  183,  449 

mucous  polyp  of,  453,  455 

myoma  of,  455 

new  growths  of,  453 

polyp    of,  differentiated   from    pro- 
lapse of  mucosa,  449 

sarcoma  of,  456 

stricture  of,  452 

a  cause  of   frequency  of   micturi- 
tion, 154 

tuberculosis   of,   differentiated   from 

cancer,  455 
Urethritis,  450 

a  cause  of  dysuria,  1">2 

of  frequency  of  micturition,  154 


INDEX 


Urethritis,  acute,  450 

chronic,  circumscribed,  451 

diffuse,  451 

Urethrocele,  differentiated  from  dislo- 
cation of  urethra,  447 
Urination,  difficult,  retarded  or  pain- 
ful, 151 

too  frequent,  153 

Urine,  analysis  of,  hi  case  records,  8 
incontinence  of,  154,  485 

a  symptom  of  abnormal   opening 

of  ureter,  487 

method  of  collecting,  hi  children,  578 
retention  of,  155 

in     incarceration     of     retroflexed 

pregnant  uterus,  155 
suppression  of,  156 
Urogenital  sinus,  Fig.  71,  198,  Fig.  157, 

392,  Fig.  160,  395 
persistence  of,  393 
Uterine  disease,  a  cause  of  hemorrhoids, 

500 

influence  of,  on  menopause,  617 
symptoms  of,  127 
Uterine     ligaments.     See     Ligaments, 

uterine 
Uterine   organs,   atrophic   changes   in, 

at  menopause,  594 
Uterine  segment,  lower,  true  hypertro- 

phic  elongation  of,  229 
Uterus,  abnormalities  of  axis  and  form 

of,  234 

absence  of,  198 
adenomyoma  of,  245 
symptoms  of,  262 
anomalies  of,  197 

due  to  arrest  of  development,  201 
due  to  arrest  of  growth,  202 
anteflexion  of,  240.     See  also  Retro- 
position  with  anteflexion 
a  cause  of  sterility,  150 
in  the  little  girl,  Fig.  90,  230 
pathological.  Fig.  91,231 
anteroposition  of.  229 
anteversion  of.  238 
ascent  of.  2 IS 

atrophic  changes  in,  in  old  age,  624 
atrophy  of.  at  menopause,  594 
congenital.  140.  203 
following  steaming,  286 


,203 

r^f'G 


Uterus,  atrophy,  of, 
non-puerperal,  203 
puerperal,  203 
bicornis,  200 

diagram  of,  Fig.  74,  199 
bicornute,  Fig.  78,  201 

pregnancy  in,  433 
bipartitus,  Fig.  72,  199,  200 
body  of,  cancer  of,  adeno-carcinoma, 

269 

early  stage  of,  Fig.  112,  269 
diagnosis  of,  276 
differential  diagnosis  of,  277 
differentiated  from  fibroid,  265 
sarcoma  of,  279,  Fig.  113,  279 
cancer  of,  266 

a  cause  of  hemorrhage  at  meno- 
pause, 619 

diagnosis  of,  in  general,  270 
in  the  child,  576 
leucorrhea  hi,  271 
symptoms  of,  270 
cavity  of,  digital  exploration  of,  94 
Kelly's  method  of  exploration  of, 

94 
Figures  illustrating,  Figs.  38-41, 

94-97 

cervix  of.     See  Cervix 
chorioepithelioma  of,  diagnosis  of,  283 
differentiated  from  fibroid,  265 
malignant,  280 
of  posterior  wall,  Fig.  114,  281 
decidua  in,  in  extra-uterine    preg- 
nancy, Fig.  143,  345 
didelphys,  Fig.  73,  199,  200 
double,  with  double  vagina,  Fig.  147, 

358 

fibro-cystic  tumor  of,  253 
fibroid  in  anterior  wall  of,  differen- 
tiated from  pregnancy,  431 
fibroids  of,  244 

a  cause  of  delayed  menopause,  604 
of   hemorrhage   at   menopause, 

617 

anemia  in,  261 
carcinoma  complicating,  255 
cervical.  247 
classification  of,  245 
complications  of,  255 
course  and  development  of,  251 


£(  JR 


INDEX 


Uterus,   fibroids  of,   dangerous  to  life, 

260 
degenerations  in,  252 

amyloid,  254 

colloid,  253 

fatty,  253 

hyaline,  253 

myxomatous,  253 

sarcomatous,  255 

in  differential  diagnosis,  264 
diagnosis  and  differential  diagnosis 

of,  262 

differentiated  from  large  ovarian 
cyst,  309 

from  small  ovarian  tumors,  298 
diseases  of  tubes  and  ovaries  com- 
plicating, 256 
edema  in,  254 

effect   of,   on  distant   organs  and 
system,  258 

on  neighboring  organs,  257 
etiology  of,  250 
fibre-cystic,  253 
frequency  of,  248 
gangrene  in,  254 
globular,   filling  pelvis,   Fig.    109, 

256 

heart  disease  in  relation  to,  259 
hemorrhage  in,  260 
in  negro  race,  249 
interstitial,  247 

diagnosis  of,  263 
interstitial   and    submucous,  Fig. 

104, 248 

intraligamentous,    246,   Fig.    105, 
249 

diagnosis  of,  263 
dysmenorrhea  in,  129 
leucorrhea  in,  261 
metastases  in,  255 
multiple,  Fig.  102,  246 

of  cervix,  247,  Fig.  108,  254 
pain  in,  261 
palpitation  in,  259 
pathology  of,  244 
pedunculated  or  polypus,  differen- 
tiated from  prolapse,  229 

in  vagina,  Fig.  107,  252 
pregnancy  interfered  with  by,  258 
renal  complications  in,  257 


Uterus,  fibroids  of,  rupture  of  uterus 

in,  260 

sarcoma  in,  264 
seedling,  251 
situation  of,  248 
sloughing,  248 
submucous,  247 
diagnosis  of,  264 
intra-uterine,  differentiated  from 

incomplete  inversion,  243 
large,  Fig.  106,  250 
pedunculated,  in  vagina,  differ- 
entiated   from    complete    in- 
version, 242 
subperitoneal,  a  cause  of  stricture 

of  ureter,  489 

differentiated    from   small  ova- 
rian tumor,  297 
subserous,  246 
diagnosis  of,  262 
differentiated  from  pelvic  cellu- 

litis,  196 

side  view  of   abdomen  contain- 
ing large,  Fig.  103,  247 
suppuration  in,  254 
symptoms  of,  260 
thrombosis  in,  255 
ureters  compressed  by,  257 
fund  us  of,  height  of,  at  various  weeks 

of  pregnancy,  Fig.  130,  306 
gravid,    changes    in,    during    early 

pregnancy,  423 
hernia  of,  233 
horizontal  section  of  body  showing 

shape  of  cavity  of,  Fig.  67,  171 
hyperinvolution  of,  a  cause  of  steril- 
ity, 150 

infantile,  140,  202,  Fig.  204,  558 
a  cause  of  amenorrhea,  140 

of  sterility,  150 
inversion  of,  240 

acute  puerperal,  Fig.  93,  239 

and    conditions   simulating,    Figs. 

94-101,  241 
diagnosis  of,  240 

differential  diagnosis  of  (table),  242 
differentiated    from    fibroid,    242, 

243,  265 

from  prolapse,  228 
lateroposition  of,  229 


INDEX 


653 


Uterus,  ligaments  of.     See  Ligaments 
lower  segment  of,  softening  of,  in 

pregnancy,  425 

maldevelopment  of,  a  cause  of  dys- 
menorrhea,  129 

amenorrhea  a  symptom  of,  419 
malpositions  of,  215 

at  menopause,  620 

mechanism  of,  219 
muscular  wall  of,  sarcoma  of,  280 
non-puerperal  atrophy  of,  203 
normal,  mobility  of,  49 
normal  position  of,  43,  Fig.  6,  44, 

Fig.  84,  216,  Fig.  150,  373 
polyp  of,  simulating  prolapse,  229 
polyp  of,  a  cause  of  hemorrhage  at 
menopause,  618 

mucous,  simulating  cancer,  273 
pregnant,  at  sixth  week,  diagramma- 
tic side  view,  during  contraction, 
Fig.  178, 423 

during   relaxation,  Fig.   177, 
422 

changes  in  shape  of,  during  early 
pregnancy,  423 

contractions  of,  424 

enlargement  of,  in  late  pregnancy, 
Fig.  181 .  428 

palpation  of,  in  late  pregnancy,  428 

ret  reflexion  and  incarceration  of, 
432 

shape  of,  in  early  pregnancy,  423 

situation  of,  in  early  pregnancy,  423 

six  weeks',  section  of.  Fig.  178,  424 
prolapse  of.  218.  Fig.  87,  223 

a  cause  of  sterility,  150 

acute,  218 

at  menopause,  620 

causation  of.  223 

diagnosis  of,  226 

differential  diagnosis  of,  228 

in  the  child.  562 

mechanism  of,  219 

partial.  Fig.  S9.  227 

pathology  of.  218 

symptoms  and  course  of.  226 
reconstruction  of.  showing  shape  of 

cavity.  Fig.  (54.  166 
retroflexion    of.    differentiated    from 

pregnancy,  431 


Uterus,  retroposition  of,  230 

with  anteflexion,  231,  Fig.  91,  231 
diagnosis  of,  232 
differentiated    from   pregnancy, 

231 

dysmenorrhea  in,  129 
retroversio-flexion  of,  234 
diagnosis  of,  236 
etiology  of,  235 
mechanism  of,  222,  235 
retroversion  of,  234,  Fig.  92,  235 
a  cause  of  menorrhagia,  137 

of  sterility,  151 

caused  by  an  overdistended  blad- 
der, Fig.  84,  218 
rudimentary,  198 
sarcoma  of,  278,  Fig.  113,  279 

in  the  child,  576 
septus,  200,  Fig.  75,  198 
souffle  of,  429 
subinvolution  of,  207 

a  cause  of  hemorrhage  at  meno- 
pause, 618 

differentiated  from  pregnancy,  431 
supra  vaginal  elongation  of,  Fig.  88, 

226 

torsion  of,  243 
transverse    longitudinal    section  of, 

Fig.  68, 172 
tubes,  vagina,  and,  development  of, 

Fig.  71,198 
unicornis,  Fig.  76,  199,  200 

with  accessory  cornu,  Fig.  77,  199 
walls  of,  structure  of,  167 

VAGINA,  absence  of,  356 

age  changes  in,  356 

anatomy  of,  354 

anterior  fornix  of,  354 

anterior    wall,  tumor    of,    differen- 
tiated from  cystocele,  368 

appearance  of,  in  early  pregnancy, 
421 

atresia  of,  a  cause  of  amenorrhea,  142 
of  dysmenorrhea,  129 
of  sterility,  150 
acquired,  359 
congenital.  357 

atrophic  changes  in,  in  old  age,  625 

atrophy  of,  at  menopause,  595 


654 


INDEX 


Vagina,  cancer  of,  383 

chorioepithelioma  of,  metastatic,  Fig. 
115,  282 

primary,  384 

secondary,  Fig.  115,  282 
column  of,  355 
condylomata  of,  384 
cross  section  of,  Fig.  151,  374 
cysts  of,  379 

in  anterior  wall,  Fig.  154.  381 

in  posterior  wall,  Fig.  153,  380 
development  of,  Figs.   158-161-162, 

395 
discharge    from,    normal,    143,    355. 

See  also  Leucorrhea 
diseases  of,  354 
displacements  of,  366 
double,  357,  Fig.  147,  358 
enterocele  of,  371 
examination  of,  in  children,  556 
fibroids  of,  381 
fistula-  of,  384 

scheme  of,  Fig.  155,  385 
foreign  bodies  in,  377 
garrulity  of,  378 
gas  in,  378 
hematoma  of,  377 
hernia  of,  368,  371 

differentiated  from  cystocele,  368 
inclusion  cyst  of  posterior  wall  of, 

Fig.  153,  380 
infantile,  examination  of,  with  cysto- 

scope,  Fig.  205,  559 
inflammations  of,  361 
injuries  of,  371 

at  menopause,  621 

due  to  coitus,  376 

due    to    falls    on    sharp    bodies, 
377 

due  to  unskillful  instrumentation, 
377 

etiology  of,  371 
longitudinal     section     of.     showing 

S-shaped  curve.  Fig.  85,  219 
malformations  of,  356 
myoma  of,  381 
new  growths  of.  379 
palpation  of,  34 
posterior  fornix  of,  355 
prolapse  of,  Fig.  88.  224 


Vagina,  sarcoma  of,  381 
in  adults,  382 
in  children,  382,  570 

septate,  357 

stenosis  of,  acquired,  359 
Vaginal  touch.     See  Touch,  vaginal 
Vaginismus,  378 

a  cause  of  dyspareunia,  146 

of  sterility,  150 
Vaginitis,  361 

a  cause  of  sterility,  150 

acute,  362 

chronic,  363 

condylomatous,  363 

diphtheritic,  362 

emphysematosa,  as  a  cause  of  gar- 
rulity of  vagina,  378 

emphysema  tous,  364 

erysipelatous,  362 

exfoliative,  differentiated  from  mem- 
branous dysmenorrhea,  131 

gonorrheal,  363 

mycotic,  364 

pseudo-diphtheritic,  362 

senile,  365 

syphilitic.  365 

tuberculous,  365 

ulcerative,  364 

with  bacillary  dysentery,  364 
Valves,  Houston's,  122 

semilunar,  of  rectum.  122,  123 
Vander  Veer,  operations  on  pregnant 

women  by  mistake,  417 
Varicocele  and  varix.     See  Ligament, 

broad,  and  Vulva 
Veit,  J.,  on  chorioepithelioma,  282 

on  garrulity  of  the  vagina  due  to  a 
gas-forming  bacillus,  378 

on  vaginal  atresia,  a  cause  of 'hema- 

tocolpos,  359 
Vesical  symptoms,  151 

at  menopause,  621 
Vestibule,  Fig.  156,  389 

anatomy  of,  390 

Vinay.L.,on  goitre  and  the  menopause, 
593 

on  sclerosis  of  the  ovaries  in  tubercu- 
losis. 59!) 
Vineberg.  views  on  lactation  atrophy  of 

uterus,  203 


INDEX 


655 


Volkmann,    on    acxite    carcinoma    of 

mastitis,  543 

Vomiting  of  pregnancy,  434 
Von  Ott  leg  holders,  57 
Vulva,  age  changes  in,  391 
anatomy  of,  388 
angioma  of,  413 
anomalies  of,  391 
at  beginning  of  third  month  of  fetal 

life,  Fig.  157,  392 
atrophic  changes  in ,  in  old  age,  625 
benign  tumors  of,  413 
cancer  of,  414 
chancre  of,  406 

differentiated  from  cancer,  415 
chancroids  of,  406 

differentiated  from  cancer,  415 
condylomata  of,  differentiated  from 

cancer,  415 

condylomata  acuminata  of,  407 
condylomata  lata  of,  407 
congestion   of,  a  cause  of  pruritus, 

161 

development  of,  392 
diagram  of,  Fig.  156,  389 
diseases  of,  388 

eczema  of,  a  cause  of  pruritus,  161 
edema  of,  405 
elephantiasis  of.  404 
fibroma  of,  413 
furunculosis  of,  differentiated   from 

chancre,  407 
gangrene  of,  405 

in  the  child,  569 
gumma  of,  408 
hematoma  of,  400 
herpes  of,  differentiated  from  chancre, 

407 
in  early  pregnancy,  appearance  of, 

421 

infantile,  Fig.  203.  556 
inflammation  of,  402 
injuries  of,  400 

due  to  coitus,  401 

due  to  direct  violence,  401 
inspection  of,  33 
itching  of.  160,  404 
lipotna  of,  413 

in  a  child,  573 
malignant  tumors  of,  414 


Vulva,  mucous  patches  of,  407 
myoma  of,  413 
myxoma  of,  413 
neuroma  of,  413 
noma  of,  405 

in  the  child,  569 
sarcoma  of,  416 
thrush  of,  403 

a  cause  of  pruritus,  161 
tuberculosis  of,  408 

differentiated  from  cancer,  415 

in  the  child,  568 

tumors  of,  a  cause  of  sterility,  150 
uncleanliness  of,  a  cause  of  pruritus, 

161 

varicose  veins  of,  405 
varix  of,  405 

a  cause  of  pruritus,  161 
venereal  lesions  of,  406 
Vulvitis,  a  cause  of  pruritus,  161 
catarrhal,  402 
diabetic,  403 

diphtheritic,  in  the  child,  569 
gonorrheal,  402 
simple,  402 

Vulvo-vaginitis  in  children,  566 
diagnosis  of,  568 
symptoms  of,  568 

WARKEH,    VAN    DE,  on    frequency   of 

strictures  of  urethra,  452 
Wathen  uterine  dilator,  Fig.  34,  92 
Webster,    J.    C.,    case    of    wandering 

spleen  in  iliac  fossa,  312 
on    renal    complications    in    fibroid 

tumors,  257 
Wertheim,  views  on  latent  gonorrhea, 

182 

Whites.     See  Leucorrhea 
Williams,  J.  W.,  cases  of  ovarian  preg- 
nancy, 245 

on  etiology  of  extra-uterine  pregnan- 
cy, 342 
on  pernicious  vomiting  of  pregnancy, 

434 

Winckel,  case  of  spontaneous  healing 
of    vesico-vaginal    fistula    following 
subsequent  pregnancy,  477 
Winter,    cancer   propaganda    in    East 
Prussia,  270 


656  INDEX 

Winter,  observations  on  the  heart  in  X-RAYS  in  diagnosis,  76 

fibroid  tumors,  259 

,    ,,  YOUNG  GIRLS,  examination  of,  25 
on    metastases    m    sarcoma    of    the 

uterus,  280  ZAPPERT,  J.,  on  genital  hemorrhages  in 
Wischmann,  C.,  case  of  precocious  ma-  the  new-born,  572 

tvirity,  504  Zweifel,  views  on  frequency  of  gonor- 
Worry,  polyuria  in,  485  rhea,  179 


DATE  DUE 


PRINTED  IN  U.S.A. 


WPlUl 
B968g 
1910 
Burrage,  Walter  L 

Gynecological  diagnosis. 


Burrage,  Walter  L 

Gynecological  diagnosis. 


1910 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


